benefit enrollment and maintenance - health insurance ...€¦ · benefit enrollment and...

Benefit Enrollment and Maintenance

This material is provided on the recipient’s agreement that it will only be used for the purpose of describing UnitedHealthcare

products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.

of 25

Specialty Benefits – Dental

Standard Companion Guide

Refers to the Technical Report Type 3 (TR3)

(Implementation Guide)

Based on X12N (Version 005010X220A1)

Companion Guide Version

[EDI - 834]


Version Number: 2.0

October 1, 2010

This material is provided on the recipient's agreement that it will only be used for the purpose of describing UnitedHealthcare

products and services to the recipient. Any other use, copying or distribution without the express written permission of

UnitedHealthGroup is prohibited.

of25

Benefit Enrollment and Maintenance UnitedHealthcare®

Healin health care. To ether:"

Change Log

Version Release Date Changes

1.0 2010-10-01 Initial External Release

2.0 2011-08-26 Updated for Specialty Benefits Dental




of 25

Preface

This Companion Guide to the ASC X12N Technical Report Type 3 (TR3), also known as Implementation Guides

(IGs), adopted under HIPAA, clarifies and specifies the data content when exchanging electronically with

UnitedHealthcare. Transmissions based on this Companion Guide, used in tandem with the X12N Implementation

Guides, are compliant with both X12N syntax and those Guides. This Companion Guide is intended to convey

information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The

Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data

expressed in the Implementation Guides.

This transaction set can be used by employers, unions, government agencies, associations, or insurance agencies to

enroll members to a payer. The payer is a healthcare organization that pays claims, administers insurance or benefit or

product. Examples of payers include an insurance company, health maintenance organization (HMO), preferred

provider organization (PPO), government agency (Medicaid, Medicare etc.) or any organization that may be contracted

by one of these former groups.

Improvements have been made to the 5010 834 layout that include updates throughout the X12N Implementation

Guide with semantic notes that more clearly define the transaction.




of 25

Table of Contents

1. INTRODUCTION ............................................................................................ 5

1.1. SCOPE ......................................................................................................... 6

1.2. OVERVIEW ................................................................................................ 6

1.3. REFERENCE .............................................................................................. 6

1.4. ADDITIONAL INFORMATION.............................................................. 6

2. GETTING STARTED ...................................................................................... 7

2.1. WORKING WITH UnitedHealthcare ...................................................... 7

2.2. TRADING PARTNER REGISTRATION ............................................... 8

2.3. CERTIFICATION AND TESTING OVERVIEW.................................. 8

2.4. TESTING WITH THE TRADING PARTNER....................................... 9

3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS ................ 10

3.1. PROCESS FLOWS................................................................................... 10

3.2. TRANSMISSION ADMINISTRATIVE PROCEDURES .................... 10

3.3. RE-TRANSMISSION PROCEDURE .................................................... 10

3.4. COMMUNICATION PROTOCOL SPECIFICATIONS..................... 10

3.5. PASSWORDS............................................................................................ 10

3.6. SYSTEM AVAILABILITY & DOWNTIME ........................................ 10

4. CONTACT INFORMATION ........................................................................ 11

4.1. EDI CUSTOMER SERVICE .................................................................. 11

4.2. EDI TECHNICAL ASSISTANCE .......................................................... 11

_Toc2870227334.3. .................................... APPLICABLE WEBSITES / E-MAIL

11

5. CONTROL SEGMENTS / ENVELOPES ..................................................... 12

5.1. ISA-IEA ..................................................................................................... 12

5.2. GS-GE ........................................................................................................ 13

5.3. ST-SE ......................................................................................................... 13

6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................... 13

7. ACKNOWLEDGEMENTS AND OR REPORTS......................................... 14

7.1. ACKNOWLEDGEMENTS ..................................................................... 14

7.2. REPORT INVENTORY .......................................................................... 14

8. TRADING PARTNER AGREEMENTS ....................................................... 14

8.1. TRADING PARTNERS ........................................................................... 14

9. TRANSACTION SPECIFIC INFORMATION ............................................. 14

10. APPENDECIES ............................................................................................. 21

10.1. IMPLEMENTATION CHECKLIST .................................................. 21

10.2. BUSINESS SCENARIOS ..................................................................... 21

10.3. TRANSMISSION EXAMPLES........................................................... 21

10.4. FREQUENTLY ASKED QUESTIONS .............................................. 21

10.5. CHANGE SUMMARY ......................................................................... 22

10.6. DEFINITIONS ...................................................................................... 23




of 25

1. INTRODUCTION

This section describes how X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of

a table. The table contains a row for each segment that UnitedHealthcare has something additional, over and above, the

information in the IGs. That information can:

1. Limit the repeat of loops, or segments

2. Limit the length of a simple data element

3. Specify a sub-set of the IGs internal code listings

4. Clarify the use of loops, segments, composite and simple data elements

5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to

trading electronically with UnitedHealthcare

In addition to the row for each segment, one or more additional rows are used to describe UnitedHealthcare’s usage for

composite and simple data elements and for any other information. Notes and comments should be placed at the

deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code

value, not in a general note about the segment.

The following table specifies the columns and suggested use of the rows for the detailed description of the transaction

set Companion Guides. The table contains a row for each segment that UnitedHealthcare has something additional,

over and above, the information in the IGs. Following is just an example of the type of information that would be

spelled out or elaborated on in: Section 9 – Transaction Specific Information (see below).

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

193 2100C NM1 Subscriber Name This type of row always exists to indicate that a new segment has begun. It is always shaded at 10% and

notes or comment about the segment itself goes in this

cell.

195 2100C NM109 Subscriber Primary

Identifier 15 This type of row exists to

limit the length of the specified data element.

196 2100C REF Subscriber Additional

Identification

197 2100C REF01 Reference

Identification Qualifier

18, 49, 6P, HJ, N6 These are the only codes

transmitted by Acme Health

Plan.

Plan Network

Identification Number

N6 This type of row exists when

a note for a particular code

value is required. For example, this note may say that value N6 is the default.

Not populating the first 3 columns makes it clear that the code value belongs to the

row immediately above it.

218 2110C EB Subscriber Eligibility or

Benefit Information

231 2110C EB13-1 Product/Service ID Qualifier

AD This row illustrates how to indicate a component data

element in the Reference column and also how to

specify that only one code value is applicable.




of 25

1.1. SCOPE

The purpose of this document is to provide the information necessary to submit 5010 834 Benefit Enrollment and

Maintenance transactions electronically to/from UnitedHealthcare. This Companion Guide is to be used in

conjunction with the ASC X12N Implementation Guides. The Companion Guide supplements, but does not

contradict or replace any requirements in the Implementation Guide. The Companion Guide specifications define

current functions and other information specific to UnitedHealthcare in processing electronic eligibility via the

5010 834 transaction.

1.2. OVERVIEW

This Companion Guide will replace, in total, the previous UnitedHealthcare Companion Guide for 5010

834 Benefit Enrollment and Maintenance (LFC-since the full name of the 834 has been addressed in section 1.1-I

would suggest just saying 834 or 5010 834 in the remainder of the document.), including the latest release dated

February 2007 and all previous releases.

This UnitedHealthcare 5010 834 Benefit Enrollment and Maintenance Companion Guide has been written to assist

you in designing and implementing 5010 834 Benefit Enrollment transactions to meet UnitedHealthcare’s

processing standards. This Companion Guide must be used in conjunction with the 5010 834 Benefit Enrollment

and Maintenance instructions as set forth by the ASC X12N Standards for Electronic Data Interchange Addenda

A1 (Version 005010X220A1), June 2010 (referred to hereafter as the Implementation Guide or IG). The

UnitedHealthcare Companion Guide identifies key data elements from the transaction set that we request you

provide to us and response we will return. The recommendations made are to enable you to more effectively

complete EDI transactions with UnitedHealthcare.

Updates to this Companion Guide will occur periodically and new documents will be posted on

www.UnitedHealthcareOnline.com > News. These updates will also be available at

http://www.uniprise.com/hipaa/Companion_docs.html and distributed to all registered trading partners with

reasonable notice, or a minimum of 30 days, prior to required Implementation.

In addition,

• Trading partners can sign up for email alerts on www.UnitedHealthcareOnline.com > News > Register

to receive important news and updates including the Network Bulletin. Information will be included in

these alerts anytime an updated 5010 834 document is posted online.

1.3. REFERENCE

For more information regarding the ASC X12N Standards for Electronic Data Interchange 5010 834 Benefit

Enrollment and Maintenance (Version 005010X220A1) and to purchase copies of these documents, consult the

Washington Publishing Company web site at: www.wpc-edi.com

1.4. ADDITIONAL INFORMATION

Assumptions

• For more information on whether an employer group or Third-Party Administrator (TPA) acting on

behalf of the employer group needs to submit enrollment data in compliance with the 5010 834

transaction standard, please consult counsel or refer to the U.S. Department of Health and Human

Services website at: http://aspe.os.dhhs.gov/admnsimp/pl104191.htm#261

• 5010 834 Health Care Benefit Enrollment and Maintenance transactions submitted to UnitedHealthcare

are assumed to be production-ready. Although the 834 file may be compliant in format,

UnitedHealthcare specific data will still need to be tested, so any files submitted to UnitedHealthcare

will not be considered production ready until implementation is complete (e.g., Plan data submitted in

HD04, Customer and Policy specific data submitted in the REF segments in Loop 2000 and 2300, etc.).

The employer groups, TPA, and system vendor(s) will have completed testing prior to submission to

ensure HIPAA compliance.

http://www.unitedhealthcareonline.com/

http://www.uniprise.com/hipaa/Companion_docs.html

http://www.unitedhealthcareonline.com/

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

http://aspe.os.dhhs.gov/admnsimp/pl104191.htm#261




of 25

2. GETTING STARTED

2.1. WORKING WITH UnitedHealthcare

Below are general guidelines that should be followed when working with UnitedHealthcare.

General File Submission Requirements

1. UnitedHealthcare strongly recommends that employer groups or TPA representing the employer group

obtain certification from an approved Third-Party Certification System and Service (TPCSS), stipulating

that its transactions are HIPAA compliant. For more information about certification and certification

vendors, speak to the appropriate Electronic Eligibility Analyst at UnitedHealthcare.

2. While UnitedHealthcare supports all of the characters in the extended character set, it is recommended

that incoming 5010 834 data use the basic character set as defined in Appendix B of the Implementation

Guide.

3. Some of the segments and data elements labeled as “Not Used” in this Companion Guide, but labeled as

“Situational” in the Implementation Guide, may still be accepted and validated to ensure HIPAA

compliance. However, UnitedHealthcare will not actually process these segments and data elements.

4. Data submitted to UnitedHealthcare in ASC HIPAA standard format may be translated into a proprietary

format for purposes of internal processing.

5. Only multiple data loops or segments should be populated with the first occurrence, and each loop or

segment populated consecutively thereafter. There should be no loops or segments without data.

6. UnitedHealthcare prefers to receive only one transaction type (records group) per interchange

(transmission). A submitter should only submit one GS-GE (Functional Group) within an ISA-IEA

(Interchange), however, UnitedHealthcare does allow multiple ST/SEs within a transaction for multi-

customer files to be submitted.

7. Trading Partners cannot send test and production information within the same transaction file,

regardless of the transaction. Test data and production data must be submitted in separate files. Notify

your Electronic Eligibility Analyst at UnitedHealthcare regarding submission of test data.

8. As of the release of this document (October 2010), UnitedHealthcare accepts the following versions of

the Implementation Guide, and any future versions as specified by the regulation:

• ASC X12N 834 (Version 005010X220A1)

Causes for Rejection of File Submission

1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as long

as the same one is used throughout the transaction. Printable characters are preferred. A carriage

return/linefeed will cause an interchange/transmission to be rejected.

2. Only loops, segments, and data elements valid for the Implementation Guide will be translated.

Submission of data that is not valid based on the Implementation Guide will cause files to be rejected.

3. If a segment or data element within a segment is specified in the Implementation Guide as “Not Used,”

yet is present in the transaction, it will be rejected as an error.

4. UnitedHealthcare will reject an interchange transmission that is not submitted with unique values in the

ST02 (Transaction Set Control Number) or GS06 (Group Control Number) elements within the

interchange transmission.




of 25

Third-Party Administrators

For employer groups’ EDI enrollment requests, it is necessary to contact the TPA directly. They will provide all

the necessary testing and submission information required.

Direct Submissions

For direct submission to UnitedHealthcare or for details regarding communication protocols, contact the

Electronic Eligibility Analyst at UnitedHealthcare who will then send the Employer or TPA an EDI transmission

questionnaire and set up the connection.

Privacy and Security Protection

UnitedHealthcare will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy

and Security regulations regarding the need to protect health information. All Trading Partners are also expected

to comply with these regulations.

Encryption Requirements

UnitedHealthcare will comply with the data encryption policy as outlined in the HIPAA Privacy and Security

regulations regarding the need to encrypt health information and other confidential data. All data within a

transaction that is included in the HIPAA definition of Electronic Protected Health Information (ePHI) will be

subject to the HIPAA Privacy and Security regulations and UnitedHealthcare will adhere to such regulations and

the associated encryption rules. All Trading Partners are also expected to comply with these regulations and

encryption policies.

2.2. TRADING PARTNER REGISTRATION

Please refer to your on-boarding process/protocol, which is available by contacting your Electronic Eligibility

Analyst at UnitedHealthcare.

2.3. CERTIFICATION AND TESTING OVERVIEW

All trading partners who wish to submit 5010 834 Benefit Enrollment and Maintenance transactions electronically

to/from UnitedHealthcare via the ASC X12N 834 (Version 005010X220A1) and receive corresponding EDI

responses must complete testing to ensure that their systems and connectivity are working correctly before any

production transactions can be processed.




of 25

2.4. TESTING WITH THE TRADING PARTNER

Testing Requirements

EDI Trading Partner Testing UnitedHealthcare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic

National Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of

testing that need to occur in order to remain in line with the health care industry’s testing

recommendations. Initially, the types of testing that UnitedHealthcare strongly recommends for the

5010 834 Transaction Set includes:

Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments, segment

order, element attributes, testing for numeric values in numeric data elements, validation of X12N or

NCPDP syntax, and compliance with X12N and NCPDP rules. This will validate the basic syntactical

integrity of the EDI submission.

Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation

Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers,

codes, elements and segments. Also included in this type is testing for HIPAA required or intra-

segment situational data elements, testing for non-medical code sets as laid out in the Implementation

Guide, and values and codes noted in the Implementation Guide via an X12N code list or table.

Type 3: Other Testing Requirements

1) We require live data for testing - not dummy data - whenever possible

2) A full file (All members) is required which includes ISA thru IEA control Segments

3) Eligibility scenarios should be tested - COBRA, Survivors, plan changes,

Dependent Only coverage, termination processing, enrollments

4) Electronic transfer must be utilized to submit the file - we can not accept a test file

via secure email since we use WTX for validation and translation

Third-Party Certification Systems and Services (TPCSS) TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their

HIPAA transactions. UnitedHealthcare requests that Trading Partners test with a TPCSS and provide

evidence of such testing. EDI submitters that have tested their 5010 834 Transaction Set with a

certification system may provide a certificate of compliance. The certificate should specify the

different types of testing passed or provide us with a certification website that indicates you have

successfully passed certain types of certification testing.

Standard Group and Eligibility Test Cases.




of 25

3. CONNECTIVITY WITH THE PAYER / COMMUNICATIONS

3.1. PROCESS FLOWS

All trading partners who wish to submit 834 transactions to UnitedHealthcare must complete testing to ensure that

their systems and connectivity are working correctly before any production transactions can be processed.

For issues or questions related to EDI Customer Service, please contact the [Electronic Eligibility Analyst] at

UnitedHealthcare.

3.2. TRANSMISSION ADMINISTRATIVE PROCEDURES

The on-boarding process can be used in batch mode (FTP or SFTP). Using these types of connections, will allow

you to either choose a manual process or automate your system.

3.3. RE-TRANSMISSION PROCEDURE

When a file needs to be retransmitted, the trading partner will contact the [Electronic Eligibility Analyst] at

UnitedHealthcare. At that time, procedures will be followed for UnitedHealthcare to accept the retransmitted file.

3.4. COMMUNICATION PROTOCOL SPECIFICATIONS

The on-boarding process currently supports the following communications methods:

• FTP with PGP for Batch

• SFTP for Batch

3.5. PASSWORDS

Passwords for your communication protocol will be supplied upon completion of the communication set up. This

information will be sent via secure email.

3.6. SYSTEM AVAILABILITY & DOWNTIME

UnitedHealthcare’s normal business hours for 834 processing are as follows:

Monday thru Saturday 7:00 a.m. thru 11:59 p.m. EST

Sunday 1:00 p.m. thru 11:59 p.m. EST

Outside these windows, UnitedHealthcare systems may be down for general maintenance and upgrades. During

these times, our ability to process incoming 834 transactions may be impacted.

In addition, unplanned system outages may also occur occasionally and impact our ability to accept or

immediately process incoming 834 transactions. We will send an email communication for scheduled and

unplanned outages.




of 25

4. CONTACT INFORMATION

4.1. EDI CUSTOMER SERVICE

For issues or questions related to EDI Customer Service, please contact the Electronic Eligibility Analyst at

UnitedHealthcare. See 10.4 - FREQUENTLY ASKED QUESTIONS

4.2. EDI TECHNICAL ASSISTANCE

For issues or questions related to EDI Technical Assistance, please contact the Electronic Eligibility Analyst at

UnitedHealthcare.

4.3. APPLICABLE WEBSITES / E-MAIL

For a copy of the 5010 Implementation Guide for 5010 834 Benefit Enrollment and Maintenance, please visit the

following:

Publication Website(s) Washington Publishing Company Washington Publishing Company (Implementation Guides)




of 25

5. CONTROL SEGMENTS / ENVELOPES

Below is the current 5010 834 interchange that reviews the usage of all included elements according to the X12N

Implementation Guide.

5.1. ISA-IEA

Transactions transmitted during a session or as a batch are identified by an interchange header segment (ISA) and

trailer segment (IEA) which form the envelope enclosing the transmission. Each ISA marks the beginning of the

transmission (batch) and provides sender and receiver identification.

Communications transport protocol interchange control header segment. This segment within the X12N

Implementation Guide identifies the start of an interchange of zero or more functional groups and interchange-related

control segments. This segment may be thought of traditionally as the file header segment.

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

C.3 ISA INTERCHANGE

CONTROL HEADER

C.4 ISA01 Authorization

Information Qualifier 00 ID – 2/2

00 = No authorization

information present

C.4 ISA03 Security Information

Qualifier 00 ID – 2/2

00 = No security information present

C.4 ISA05 Interchange ID Qualifier ZZ or 30 ID – 2/2 ZZ = Mutually Defined

C.4

ISA06

Interchange Sender ID

Client/TPA to UHC = User

defined value

AN – 15/15

Interchange Sender ID. Left justify and pad with

spaces to 15 characters.

C.5 ISA07 Interchange ID Qualifier ZZ ID – 2/2 ZZ = Mutually Defined

C.5

ISA08

Interchange Receiver ID

Client/TPA to UHC =

4102656033

AN – 15/15

Receiver ID. Left justify and pad with spaces to 15

characters.

C.5 ISA11 Repetition Separator * 1/1 The delimiter in ISA11 must be an asterisk

C.6 ISA16 Component Element

Separator : 1/1

The delimiter in ISA16

must be a colon

Communications transport protocol interchange control trailer segment. This segment within the X12N

Implementation Guide defines the end of an interchange of zero or more functional groups and interchange-related

control segments. This segment may be thought of traditionally as the file trailer record.




of 25

5.2. GS-GE

EDI transactions of a similar nature and destined for one trading partner may be gathered into a functional group,

identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS

segment marks the beginning of a functional group. There can be many functional groups within an interchange

envelope. The number of functional groups that exist in the transmission could be found in IEA01 element.

Communications transport protocol functional group header segment. This segment within the X12N

Implementation Guide indicates the beginning of a functional group and provides control information concerning

the batch of transactions. This segment may be thought of traditionally as the batch header record.

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

C.7

GS

FUNCTIONAL

GROUP HEADER

To indicate the beginning of a

functional group and to

provide control information

C.7

GS02

Application Sender’s

Code

Direct to UHC

Vision = User

Defined

AN – 2/15

The value will be sent by the trading partner

C.7

GS03

Application Receiver’s

Code

Direct to UHC =

4102656033

AN – 2/15

This is the same value as the

Receiver’s Interchange ID from ISA08 (do not pad with spaces).

Communications transport protocol functional group trailer segment. This segment within the X12N

Implementation Guide indicates the end of a functional group and provides control information concerning the

batch of transactions. This segment may be thought of traditionally as the batch trailer record.

5.3. ST-SE

The beginning of each individual transaction is identified using a transaction set header segment (ST). The end of

every transaction is marked by a transaction set trailer segment (SE).

Communications transport protocol transaction set header segment. This segment within the X12N

Implementation Guide indicates the start of the transaction set and assigns a control number to the transaction.

This segment may be thought of traditionally as the eligibility header record.

Communications transport protocol transaction set trailer. This segment within the X12N Implementation Guide

indicates the end of the transaction set and provides the count of transmitted segments (including the beginning

(ST) and ending (SE) segments). This segment may be thought of traditionally as the eligibility trailer record.

6. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

Future Terminations - When sending a full file you must send the termed record through the physical termination date.

For example; if the file is sent on Aug 2nd and a record contains an Aug 31st term date, UHC must receive the same

record with the same term date until the termination date passes. If the record falls off the next file sent (before the

actual term date) the record will terminate on the date the file is loaded.

Effective Dates - If a record is sent without an effective date the system will insert the date the file is loaded as the

effective date.

Once an effective date is received on a file for the first time and loaded in our system that effective date will remain in

our system and will not be overwritten by a different effective date on a future file.




of 25

7. ACKNOWLEDGEMENTS AND OR REPORTS

7.1. ACKNOWLEDGEMENTS

For every transaction received, there is an expected response. The available responses include:

• [999] – A Functional Acknowledgement

Once the transaction has passed the “front end” compliance check it then goes through a syntax compliance edit.

This edit is to verify the compliance within the ASC X12N syntax according to the HIPAA Implementation

Guides. The transaction will receive a Functional Acknowledgement [999] to provide feedback on the transaction.

The [999] functional acknowledgement contains accepted or rejected information. If the transaction contains any

syntactical errors, the segments and elements in which the error occurred will be reported in a rejected

acknowledgement. If the transaction contained no syntactical errors, a positive [999] response will be generated

and the transaction is passed on for subsequent processing.

7.2. REPORT INVENTORY

An edit report will produce after each file load highlighting changes such as additions and terminations as well as

any errors that may have occurred during the file load. If a file load contains errors the edit report will be sent by

the assigned eligibility analyst to the identified contact. The contact can also request a copy of the edit report for

all file loads regardless if an error occurs.

An Error report template is attached below.

Group Error

Report-Template.xls Elig Error Report-

Template.xls

8. TRADING PARTNER AGREEMENTS

This section contains general information concerning Trading Partner (External Access) Agreements (TPA), which is

available by contacting your [Electronic Eligibility Analyst] at UnitedHealthcare.

8.1. TRADING PARTNERS

Direct Connection – The Trading Partner (External Access) Agreement must be signed and completed prior to set

up.

9. TRANSACTION SPECIFIC INFORMATION

This section is reserved for any additional information, over and above the information contained in the IGs, that

UnitedHealthcare requires in order to electronically submit 5010 834 Benefit Enrollment and Maintenance transactions.

834 Transaction Set Detail:

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

48 2000 INS01 Subscriber indicator

Y,N

1 Y = Subscriber / N = Dependent .This identifies whether the enrollee is the




of 25

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

subscriber or dependant

48 2000 INS02 Relationship Code 01,03,04,05,06,07,08, 09, 10,11,12,13,14,15,17,

18,

19,23,24,25,26,31 ,38

2 Subscriber information(INS02=’18’) must precede dependent

information

49 2000 INS03 Maintenance Type Code 001, 021, 024, 025 and 030

3

49 2000 INS04 Maintenance Reason

Code

01, 02, 03, 04, 05, 06,

07, 08, 09, 10, 11, 14, 15, 16, 17, 18, 20, 21,

22, 25, 26, 27, 28,

29, 31, 32, 33,

37, 38, 39, 40, 41,

43, AI, XN, XT,

59, AA, AB, AC, AD,

AE, AF, AG, AH, AJ, AL, EC

2/3

51 2000 INS05 Benefit Status Code A,C,S T 1 52 2000 INS07 COBRA Event Code 1, 2, 3, 4, 5, 6, 7, 8,

9, 10 and ZZ 1/2

52 2000 INS08 Employment Status

Code

AO,AU,FT,L1,PT,R

T,TE

2

53 2000 INS09 Student Status Code F,N,P 1 Used when describing a Non-spouse dependent.

F=Full-time/N=Not a

Student P=Part-time

53 2000 INS10 Handicap Indicator Y,N 1 N =No / Y =Yes

54 2000 INS17 Birth Sequence Number 1/9 55 2000 REF02 Will have SSN when

REF01 is “OF” Will have group or

company code/Subcode when REF01 is “1L”

63 2100A NM103 Last Name This element contains the

last name of the enrollee

63 2100A NM104 First Name This element contains the first name of the enrollee

63 2100A NM105 Middle Name This element contains the middle name of the enrollee

64 2100A NM109 Identification Code When NM108 is ‘34’ and INS01 = ‘Y’, this would

contain the subscriber

SSN. When NM108 is ‘34’ and

INS01 = ‘N’, this element would contain the dependant SSN.

65 2100A PER Member Communication

Numbers This segment contains the

work phone, home phone

and cell phone numbers of the members

66 2100A PER03 Communication Number

Qualifier CP- Cellular Phone HP- Home Phone Number

2 This element contains the qualifier indicating whether the




of 25

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

WP- Work Phone

Number communication number in

the following element is a cell phone, work phone or home phone number

66 2100A PER04 Communication Number 256 This element contains the appropriate phone number(cell phone, home

phone or work phone) Our system can store only the 10 characters

communication number.

66 2100A PER05 Communication Number Qualifier

CP- Cellular Phone HP- Home Phone

Number

WP- Work Phone

Number


communication number in

the following element is a cell phone, work phone or

home phone number

67 2100A PER06 Communication Number 256 This element contains the

appropriate phone

number(cell phone, home

phone or work phone). Our system can store only the

10 characters communication number.

67 2100A PER07 Communication Number Qualifier

CP- Cellular Phone HP- Home Phone

Number

WP- Work Phone Number


communication number in the following element is a cell phone, work phone or

home phone number

67 2100A PER08 Communication Number 256 This element contains the

appropriate phone

number(cell phone, home

phone or work phone) Our

system can store only the

10 characters communication number.

68 2100A N301 Address1 55 Member's Address or Dependents address if different from member.

Our system can store only

30 characters of address 1 data, rest of the data will

be truncated

68 2100A N302 Address2 55 Member's Address or Dependents address if

different from member. Our system can store only 30 characters of address 2

data, rest of the data will

be truncated

69 2100A N401 City 30 Member's City or

Dependents city if different from member. Our system can store only 20

characters of city data, rest of the data will be truncated

69 2100A N402 State 2 Member's State or dependents state if different from member




of 25

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

69 2100A N403 Zip+4 15 Member's Zip Code or

dependents zip if different

from member – include

leading zeros. The maximum length for the

zip code field in system for the US address is 9 (Zip5 +

Zip 4), but foreign address zip code can be up to 15 digit alphanumeric

71 2100A DMG02 Birth date 8 DOB – Required for both member and dependent. Format is CCYYMMDD

72 2100A DMG03 Gender M-Male F-Female

U-Unknown

1 M-Male F-Female

U-Unknown

72 2100A DMG04 Marital Status B -Registered Domestic Partner D -Divorced

I -Single M -Married R -Unreported

S -Separated

U -Unmarried (Single or Divorced

or Widowed) W -Widowed X- Legally Separated

1 For member only

76 2100A EC Employment Class This segment contains the member employment class details.

76 2100A EC01 Employment Class Code 01 Union 02 Non-Union

03 Executive

04 Non-Executive 05 Management

06 Non-Management

07 Hourly 08 Salaried

09 Administrative

10 Non- Administrative

11 Exempt 12 Non-Exempt 17 Highly

Compensated

18 Key-Employee 19 Bargaining

20 Non-Bargaining

21 Owner 22 President

23 Vice President

2 Contains the employment class code of the employee


03 Executive

04 Non-Executive 05 Management 06 Non-Management


09 Administrative

10 Non- Administrative 11 Exempt





of 25

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

12 Non-Exempt

17 Highly

Compensated 18 Key-Employee

19 Bargaining

20 Non-Bargaining 21 Owner

22 President

23 Vice President


03 Executive 04 Non-Executive

05 Management

06 Non-Management


09 Administrative 10 Non-

Administrative

11 Exempt 12 Non-Exempt

17 Highly

Compensated 18 Key-Employee

19 Bargaining

20 Non-Bargaining 21 Owner

22 President

23 Vice President


84 2100A LUI Member Language This segment would

contain the member language details.

84 2100A LUI01 Identification Code

Qualifier

LD,LE 2 LD - NISO Z39.53

Language Codes

LE - ISO 639 Language Codes

85 2100A LUI02 Language Identification Code

2 It contains the Member language identification code.

85 2100A LUI04 Use of Language Indicator

5,6,7,8 1 It contains skills of the language usage for the

person.

5- Language Reading

6 -Language Writing

7 -Language Speaking 8 -Native Language

88 2100B NM109 Incorrect SSN 9 When NM101 is ‘70’.

Old or incorrect SSN

Used when previously sent SSN needs to be corrected

90 2100B DMG02 Incorrect DOB 9 When NM101 is ‘70’. Used when previously sent

DOB needs to be corrected

142 2300 HD05 Coverage Level Code EMP/IND-Employee only

E1D-Employee and 1 dependent ECH-Employee and

Children

3




of 25

Page

Loop Id

Reference

Name

Codes

Length

Notes/Comments

FAM-Family

ESP-Employee and

Spouse Others converted to

FAM

59 2000 DTP03 Hire Date/Employment Begin Date/Employment

End date

When DTP01 is "336" means Hire date, When DTP01 is “356” means

Employment Begin date and When DTP01 is “357” means Employment End

date .

144 2300 DTP03 Coverage Begin Date when DTP01 is "348"

144 2300 DTP03 Coverage End Date when DTP01 is "349"

834 Transaction Set Header :

Page

Loop Id

Reference

Name

Codes Lengt

h

Notes/Comments

31 ST 01=834 Transaction Set Id Code 3 Header, Transaction Set Identifier Code

31 ST 02 Transaction Set Control

Number 9 Header, Transaction Set

Control Number

31 ST03 Implementation

Convention Reference 35 This will contain the version

number. 005010X220A1

32 BGN 01 Transaction Set Purpose Code

4 Header, Transaction Set Purpose Code, 00=Original,

15=Re-submission and

22=Information Copy

33 BGN 02 BGN Reference ID 30 33 BGN 03 BGN Date 8 Transaction Date, Format is

CCYYMMDD

33 BGN 04 BGN Time 6 Transaction Time, Format is

HHMM

35 BGN 08 Transaction Action Code 2 2=Change, 4=Verify and RX

= Replace (if the value is 4 or RX, then the file will be considered as Full file)

36 REF 02 Transmission Type ID 30 when REF 01=38 (Master Policy Number)

40 N104 Sponsor Federal Tax ID 80 when N101=P5 and N103=FI

40 N104 Payer Federal Tax ID 80 when N101=IN and N103=FI

834 Transaction Set Trailer :

Page

Loop Id

Reference

Name

Codes Lengt

h

Notes/Comments

184 SE 01 Number of Included

Segments 10 Trailer, Number of Included

Segments

184 SE 02 Transaction Control Number

9 Trailer, Transaction Control Number which is match in

ST02

A Generic Example of HIPAA Compliant Enrollment Transaction Set:

This material is provided on the recipient's agreement that it will only be used for the purpose of describing UnitedHealthcare

products and services to the recipient. Any other use, copying or distribution without the express written permission of

UnitedHealthGroup is prohibited.

of25

Benefit Enrollment and Maintenance UnitedHealthcare®

Healin health care. To ether:"




of 25

10. APPENDECIES

10.1. IMPLEMENTATION CHECKLIST

Your trading partners are the organizations with which you exchange transactions. The final step before going

“live” with the 5010 transactions will be to complete testing with your trading partners. The testing will involve

sending test transactions through the channels you use today, such as to the clearinghouses or payers. Sending test

transactions is an opportunity to see if they will be received successfully, both by your trading partner’s system

and your system. Be aware, however, that in some instances, testing will be done in live production environments

with a subset of your transaction data.

Use the following steps to prepare for the Implementation of 5010:

1. Talk to your current practice management system vendor.

2. Talk to your clearinghouses or billing service, if you use either one, and health insurance payers.

3. Identify changes to data reporting requirements.

4. Identify potential changes to existing practice work flow and business processes.

5. Identify staff training needs.

6. Test with your trading partners, (e.g., payers and clearinghouses).

7. Budget for Implementation costs, including expenses for system changes, resource materials, consultants,

and training.

10.2. BUSINESS SCENARIOS

Please refer to Section 4.4 above, which points to the appropriate Website where the reader can view the

Implementation Guide, which contains various business scenario examples.

10.3. TRANSMISSION EXAMPLES

Please refer to Section 4.4 above, which points to the appropriate Website where the reader can view the

Implementation Guide, which contains various transmission examples.

10.4. FREQUENTLY ASKED QUESTIONS

1) Will UHC test my data when it is received?

Yes, the Eligibility Team will run each production file through testing and Quality Assurance to ensure that your file was transmitted and loaded as expected.

2) Who should I notify if there would be a large increase or decrease in membership (example: open

enrollment period)?

Notify your assigned Eligibility Analyst (Eligibility Team) as soon as you are aware of when the increase/decrease will take place. UHC appreciates advance notice and can override systems checks and error reporting that notifies us of such results outside of normal tolerances.

3) Who do we notify if there is an address or contact name change for the group?

Please notify your UHC Account Executive/Account Manager.

4) How often should I send my file?

Most groups send full eligibility files once every month. You may send an eligibility file more frequently depending on the amount of changes you have to report. The frequency of file submissions should be coordinated with your UHC Eligibility Analyst (Eligibility Team) and your Account




of 25

Executive/Account Manager so that we may monitor the frequency of your file loads and notify when files are overdue.

5) How quickly will UHC load my file?

Data that is incorrect in terms of file/record layout or that contains other errors may be subject to a delay in loading. UHC’s standard is to load files within 24-48 business hours of receipt. If the file cannot be loaded at all due to a physical defect or other error conditions, you will be notified as soon as possible in order to provide a replacement file.

6) What is the difference between full file and a transaction (trans)/change file?

A full replacement file contains records of all eligible members (and dependents). UHC recommends a full replacement file for every file transmission. The full replacement file is used as a reference for any eligibility verification questions. A transaction (trans)/change file would include changes only and is not the preferred file type.

7) What is Data Encryption?

Encryption is a process that re-formats your data in to a format that can only be read by the receiver after the use of a decryption key. This protects the content of your file from anyone who may obtain it in an unauthorized fashion. UHC Vision strongly recommends encryption of files. PGP is an encryption/decryption product that is in use by UHC Vision.

10.5. CHANGE SUMMARY

For those business segments for which previous Companion Guide(s) do exist, the current Companion Guide

refers to the 5010 Implementation of the transaction set, whereas the previous Companion Guide(s) refer to earlier

HIPAA release standards such as [4010/4010A1].



of 25


10.6. DEFINITIONS

Term Qualifier Definition 834 834 – Inbound file containing Benefit Enrollment and Maintenance

data

999 999 – or Functional Acknowledgement for HIPAA 834 file. A functional acknowledgement will be sent by the receiver to the sender when an 834 file is received.

4010 4010 – The October 1997 ASC X12N standard format, Version 4, Release 1, Sub-release 0 (00[4010])

4010A1 4010A1 – The version of the transactions named in HIPAA is Version 004010 (4010) and its subsequent addenda, 004010A1 (4010A1), are collectively referred to as “4010A1.” These electronic transactions

were developed by the standards development organization Accredited Standards Committee X12N (ASC X12N). Standards development

organizations are bodies that develop standards used in various

industries, such as banking standards that enable you to use your ATM card in any ATM.

5010 5010 – The August 2006 ASC X12N standard format, Version 5, Release 1, Sub-release 0 (005010).

Acknowledgement Acknowledgement – The Acknowledgement is the electronic response, or 999, or Functional Acknowledgement for HIPAA 834 file.

ASC X12N ASC X12N – is the official designation of the U.S. national standards body for the development and maintenance of Electronic Data

Interchange (EDI) standards. EDI X12N (Electronic Data Interchange) is a data format based on ASC X12N standards. It is used to exchange specific data between two or more trading partners.

B2B B2B – Business-to-business, or "B2B," is a term commonly used to describe electronic commerce transactions between businesses, as

opposed to those between businesses and other groups, such as business and individual consumers (B2C) or business and government (B2G).

B2B – is also commonly used as an adjective to describe any activity, be it marketing, sales, or ecommerce that occurs between businesses and other businesses rather than between businesses and consumers.

CAQH CAQH – is an unprecedented nonprofit alliance of health plans and trade associations, and is a catalyst for industry collaboration on initiatives that simplify healthcare administration. CAQH solutions

promote quality interactions between plans, providers, and other stakeholders; reduce costs and frustrations associated with healthcare

administration; facilitate administrative healthcare information exchange and encourage administrative and clinical data integration.

Companion Guide Companion Guide – A handbook that assists with giving information and instructions on the EDI 834 transactions.

CORE CORE – Committee on Operating Rules for Information Exchange – a segment of CAQH whose mission is to promote interoperability of

transactions among healthcare payers. http://www.caqh.org/CORE_overview.php

EDI EDI – Electronic Data Interchange is the computer-to-computer

exchange of business or other information between two organizations

(trading partners). The data may be either in a standardized or

proprietary format. Also known as electronic commerce.

EDI 834 EDI 834 – The 834 EDI Transactions can be used by employers, unions, government agencies, associations or insurance agencies to enroll members to a payer. The payer is a healthcare organization that

pays claims, administers insurance or benefit or product. Examples of payers include an insurance company, health care professional (HMO), preferred provider organization (PPO), government agency (Medicaid,

Medicare etc.) on any organization that may be contracted by one of these former groups.

http://www.caqh.org/CORE_overview.php



of 25


Term Qualifier Definition

EDI X12N Standards and Releases

EDI X12N Standards and Releases – EDI X12N is governed by standards released by ASC X12N (The Accredited Standards

Committee). Each release contains set of message types like invoice, purchase order, healthcare claim, etc. Each message type has specific

number assigned to it instead of name. For example: an invoice is 810, purchase order is 850 and healthcare claim is 837, Eligibility is 834

Every new release contains new version number. Version number examples: 4010, 4020, 4030, 5010, 5030, etc. Major releases start with new first number. For example: 4010 is one of the major releases, so is

5010. However 4020 is minor release. Minor releases contain minor changes or improvements over major releases. Understanding the

difference between major and minor releases is important. Let say you have working translation for some messages for release 4010, and if

you want to upgrade to 4020 you will notice only a few changes between the two, and if you want to upgrade to release 5010 you might

need to make a lot of modifications to current translation. At the time

of this writing 4010 is most widely used release. It is the first release

that is Y2K compliant.

Most of HIPAA based systems know and use 4010. Conclusion: to translate or validate

EDI X12N data you need to know transaction number (message numeric name) and release version number. Both of those numbers are inside the file.

HIPAA HIPAA – Health Insurance Portability and Accountability Act of 1996 is a federal law intended to improve the availability and continuity of health insurance coverage that, among other things, places limits on

exclusions for pre-existing medical conditions; permits certain individuals to enroll for available group health care coverage when they lose other health coverage or have a new dependent; prohibits

discrimination in group enrollment based on health status; provides

privacy standards relating to individuals' personally identifiable claim- related information; guarantees the availability of health coverage to

small employers and the renewability of health insurance coverage in the

small and large group markets; requires availability of non-group coverage for certain individuals whose group coverage is terminated;

and establishes standards for electronic transmissions.

ICD-9 ICD-9 – ICD-9 is an acronym used in the medical field that stands for International Classification of Diseases, ninth revision. In the United

States, the ICD-9 covered the years 1979 to 1998. Currently, ICD-10,

which is the tenth revision, is in effect as the most current database of disease classifications. ICD-9 was used in the US until the 10th revision became fully implemented in 1998, though the actual revision

was concluded some years earlier.

ICD-10 ICD-10 – The International Statistical Classification of Diseases

and Related Health Problems 10th Revision (ICD-10) is a coding of

diseases and signs, symptoms, abnormal findings, complaints, social

circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). The code set allows more than

155,000 different codes and permits tracking of many new diagnoses and procedures, a significant expansion on the 17,000 codes available

in ICD-9.

Protocols Protocols – Protocols are codes of correct conduct for a given

situation.

Qualifier Qualifier – A qualifier is a word, number, or characters that modifies or limits the meaning of another word or group of words or dates.

Segment Segment – a string of data elements that contain specific values based on the loop and data element on file which is separated into specific

sections.



of 25


Term Qualifier Definition

Third Party Administrator (TPA)

Third party administrator – TPA’s are prominent players in the managed care industry and have the expertise and capability to

administer all or a portion of the claims process. They are normally contracted by a health insurer or self-insuring companies to administer services, including claims administration, premium collection, no

enrollment and other administrative activities. A hospital or provider organization desiring to set up its own health plan will often outsource certain responsibilities to a TPA.

Trading Partner Trading Partner – A Trading Partner may represent an organization,

group of organizations or some other entity. In most cases it is just an organization or company.

Trading Partner

Requirements Trading Partner Requirements – EDI X12N standard covers number

of requirements for data structure, separators, control numbers, etc. However many big trading partners impose they own even more strict

rules and requirements. It can be everything: specific data format requirements for some elements, requirement to contain specific

segments (segments that are not mandatory in EDI X12N standard

being made mandatory), etc. In HIPAA those specific trading partner requirements are usually listed in separate document called Companion Guide. It is essential to follow these documents to the letter when

implementing EDI systems.

benefit enrollment and maintenance - health insurance ...€¦ · benefit enrollment and...

Documents