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5010 Transactions

Health New England X12 834 5010 Benefit Enrollment and Maintenance Companion Guide

HNE has developed the following Companion Guide as a support tool for our Trading Partners when submitting electronic HIPAA 5010 Membership Enrollment. HNE accepts such enrollment in the format described in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12 834, version 005010. (We also may refer to this as the TR3, or “the Guide.”) HNE will accept enrollment in the format consistent with form 005010X220A1, published in June 2010. This Guide may be purchased from the Washington Publishing Company at http://www.wpc-edi.com.

Our Trading Partners may select from several different options for filing enrollment electronically:

Clearinghouses (Third Party Administrators) – For a complete list of Clearinghouses that HNE transacts with, see Clearinghouse_List_final.pdf.
Employer Groups can submit files through HNEDirect, our secure website (HNE Employer Groups only).
All Trading Partners can submit files to our FTP server
HNE can retrieve files from a Trading Partner’s FTP server.

If you are not filing your enrollment electronically and you would like more information, please contact your Employer Group’s HNE Sales Representative.

EDI files are processed on business days at 10:00 AM and 5:00 PM. Files received after 5:00 PM will be processed at 10:00 AM the next business day.

Health New England follows the Basic Character Set found in the HIPAA 834 Implementation Guide Table B.1 in appendix B.1.1.2.2 Basic Character Set.

Purpose: The 834 Companion Guide was created for Health New England trading partners to supplement the 834 Implementation Guide. It describes the data content, business rules and characteristics of the 834 transaction that is created by Employer Groups and Third Parties for transmission to Health New England.

Envelope Structure

We understand that we are only one of your many Trading Partners – we do not expect you to customize your content just for us. HNE uses ECMap® and ECGateway® from Sybase to process EDI (X12) transactions. Because of the flexibility of this software, we have a limited number of filing requirements. These are described below:

Segments per line: We do not require EDI files with one segment per line. EDI files may be submitted as one continuous string of text.

Delimiters: We have no standard or preference for delimiters. If you have no standard or preference, follow the TR3. See Table B.5 in Appendix B.1.1.2.5

Control Numbers: At least one of the ISA, GS and ST control numbers must increment from one day to the next. Although this is left to your preference, please note below the effect that this may have on the 997 Functional Acknowledgment/999 Implementation Acknowledgement.

997 Functional Acknowledgement/999 Implementation Acknowledgement transaction: The 997 Functional Acknowledgment/999 Implementation Acknowledgement transaction does not reflect the ISA control number received on the 834 Enrollment. If you want to use the 997/999 to reconcile the 834 (or any other transaction we do in the future) then the GS and/or ST control numbers should increment from day to day.

Multiple submissions: There are no restrictions for multiple submissions:

HNE can accept multiple ISA-IEA envelopes within a single file.
HNE can accept multiple GS-GE envelopes within a single ISA-IEA interchange.
HNE can accept multiple ST-SE envelopes within a single GS-GE functional group.
HNE can accept multiple Members (2000 loop) within a single ST-SE transaction.

Health New England-Specific Requirements

The following section outlines specific instructions, recommendations, and conditional data requirements for transactions being submitted to Health New England. This information is provided to assist trading partners in the construction of their transactions in a manner that will allow Health New England to process their transactions in the most efficient manner possible.

Interchange Control Header and Functional Group Header Values

Loop

Segment

Element Name

Companion Information

----

ISA01

Authorization Information Qualifier

----

ISA02

Authorization Information

10 spaces

----

ISA03

Security Information Qualifier

----

ISA04

Security Information

10 spaces

----

ISA05

Interchange ID Qualifier

HNE can accept all other codes listed in Appendix C.1, however HNE would prefer 30. Please do not use the value ZZ.

----

ISA06

Interchange Sender ID

Assign the value based on the qualifier in ISA05. If you use 30 in ISA 05, please use your U.S. Federal Tax Identification Number.

----

ISA07

Interchange ID Qualifier

HNE can accept 01 or 30; however, HNE would prefer 30. Please do not use the value ZZ.

----

ISA08

Interchange Receiver ID

Based on which qualifier you use in ISA07, these values can be used;

Qualifier	Value
01	152427324
30	042864973

----

ISA09

Interchange Date

Format is YYMMDD

----

ISA10

Interchange Time

Format is HHMM

----

ISA11

Repetition Separator

----

ISA12

Interchange Control Version

00501

----

ISA13

Interchange Control Number

Must be identical to the associated control trailer IEA02

----

ISA14

Acknowledgement Requested

0 = no acknowledgment requested

At this time HNE cannot generate a TA1 Interchange Acknowledgment

----

ISA15

Interchange Usage Indicator

T = Test data

P = Production data

----

ISA16

Component Element Separator

----

GS01

Functional Identifier Code

----

GS02

Application Sender’s Code

HNE can accept anything, but prefers to mimic what is in ISA06

----

GS03

Application Receiver’s Code

HNE can accept anything, but prefers to mimic what is in ISA08

----

GS04

Date

Format is CCYYMMDD

----

GS05

Time

Format is HHMM

----

GS06

Group Control Number

Must be identical to the associated functional group trailer GE02

----

GS07

Responsible Agency Code

----

GS08

Version/Release/Industry Identifier Code

005010X220A1

Common Segment Values

Loop	Segment	Element Name	Companion Information
----	ST03	Implementation Convention Reference	005010X220A1
----	BGN01	Transaction Set Purpose Code	Code Definition 00 Original 15 Resubmission 22 Information Copy
----	BGN08	Action Code	Code Definition 2 Change/Update 4 Verify (audit)
----	DTP01	Date Time Qualifier	Code Definition 007 Effective
----	DTP02	Date Time Period Format Qualifier	Code Definition D8 Date
----	DTP03	Date Time Period	Current date expressed in format CCYYMMDD

Benefit Enrollment and Maintenance Specific Values

Loop	Segment	Element Name	Companion Information
1000A	N101	Entity Identifier Code	Code Definition P5 Plan Sponsor
1000A	N102	Plan Sponsor Name	Plan Name
1000A	N103	Identification Code Qualifier	Code Definition FI Federal Taxpayer’s Identification Number
1000A	N104	Identification Code	Plan Tax Id
1000B	N101	Entity Identification Code	Code Definition IN Insurer
1000B	N102	Insurer Name	Health New England
1000B	N103	Identification Code Qualifier	Code Definition FI Federal Taxpayer’s Identification Number
1000B	N104	Identification Code	152427324
1000C	N101	Entity Identifier Code	Code Definition TV Third Party Administrator
1000C	N102	TPA or Broker Name	TPA Name
1000C	N103	Identification Code Qualifier	Code Definition FI Federal Taxpayer’s Identification Number
2000	INS01	Subscriber Indicator	Code Definition N No Y Yes
2000	INS02	Individual Relationship Code	Code Definition 01 Spouse 05 Grandson or Granddaughter 07 Nephew or Niece 09 Adopted Child 10 Foster Child 15 Ward 17 Stepson or Stepdaughter 18 Self 19 Child 23 Sponsored Dependent 24 Dependent of a Minor Dependent 25 Ex-Spouse 38 Collateral Dependent 43 Federal Dependent (classification used by the GIC only) 53 Life Partner ZZ Mutually Defined (classification used by the GIC only)
2000	INS03	Maintenance Type Code	All implementation guide codes are usable by HNE
2000	INS04	Maintenance Reason Code	All implementation guide codes are usable by HNE with the following exceptions; Code Definition 27 Pre-Enrollment 37 Leave of Absence with Benefits 39 Lay Off with Benefits XN Notification Only
2000	INS05	Benefit Status Code	Code Definition A Active C COBRA
2000	INS06-1	Medicare Plan Code	All implementation guide codes are usable by HNE
2000	INS06-2	Eligibility Reason Code	All implementation guide codes are usable by HNE
2000	INS07	COBRA Qualifying Event	All implementation guide codes are usable by HNE
2000	INS08	Employment Status Code	Code Definition AC Active FT Full-Time RT Retired
2000	INS09	Student Status Code	Currently not used due to Health Care Reform
2000	INS10	Handicap Indicator	Code Definition N No Y Yes
2000	INS11	Date of Death Format Qualifier	D8 – If member is deceased
2000	INS12	Date of Death	Format is CCYYMMDD – If member is deceased
2000	INS13	Confidentiality Code	Code Definition R Restricted Access *Only when required to protect member
2000	REF01	Reference Identification Number	Code Definition 0F Subscriber Number
2000	REF02	Subscriber Identifier	SSN of the Subscriber is preferred
2000	REF01	Reference Identification Number	Code Definition 1L Group or Policy Number
2000	REF02	Group or Policy Number	HNE’s internal division number is preferred
2000	REF01	Reference Identification Number	Code Definition 23 Client Number *Used only when the HNE internal member number is known
2000	REF02	HNE Member Number	The internal HNE member number
2000	DTP01	Member Level Date Time Qualifier	Code Definition 050 Received 303 Maintenance Effective 336 Employment Begin (hire date) 340 COBRA Begin (cobra only) 341 COBRA End (cobra only) 356 Eligibility Begin 357 Eligibility End (term only) 383 Adjusted Hire (hire date) 385 Credited Service Begin 394 Credited Service End
2000	DTP02	Date Time Period Format Qualifier	D8
2000	DTP03	Date Time Period	Format is CCYYMMDD
2100A	NM101	Entity Identifier Code	Code Definition 74 Corrected Insured – Must have loop 2100B IL Insured or Subscriber
2100A	NM102	Entity Type Qualifier	1
2100A	NM103	Name Last	Last name
2100A	NM104	Name First	First name(s)
2100A	NM105	Name Middle	Middle initial only
2100A	NM106	Name Prefix
2100A	NM107	Name Suffix
2100A	NM108	Identification Code Qualifier	Code Definition 34 Social Security Number
2100A	NM109	Member Identifier	Member’s SSN
2100A	PER01	Contact Function Code	Code Definition IP Insured Part
2100A	PER03	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100A	PER04	Communication Number
2100A	PER05	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100A	PER06	Communication Number
2100A	PER07	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100A	PER08	Communication Number
2100A	N301	Address Street Line 1
2100A	N302	Address Street Line 2
2100A	N401	Address City
2100A	N402	Address State
2100A	N403	Address Zip
2100A	N404	Address Country
2100A	DMG01	Date Time Period Format Qualifier	D8
2100A	DMG02	Member Birth Date	Format is CCYYMMDD
2100A	DMG03	Gender Code	Code Definition F Female M Male
2100A	DMG04	Marital Status Code	All implementation guide codes are usable by HNE
2100A	DMG05-1	Race or Ethnicity Code	All implementation guide codes are usable by HNE
2100A	DMG05-2	Code List Qualifier Code	Code Definition RET Classification of Race or Ethnicity
2100A	DMG05-3	Industry Code	Code supplied by CDC via implementation guide code source 859
2100A	AMT01	Amount Qualifier Code	Code Definition C1 Co-Payment Amount *MassHealth use only
2100A	AMT02	Monetary Amount	*MassHealth use only
2100A	LUI01	Identification Code Qualifier	Code Definition LD NISO Z39.53 Language Codes LE ISO 639 Language Codes
2100A	LUI02	Identification Code
2100A	LUI03	Language Code	Text field for when LUI01 & LUI02 are not used
2100B	NM101	Entity Identifier Code	Code Definition 70 Prior Incorrect Insured – Must have loop 2100A NM101 set to 74
2100B	NM102	Entity Type Qualifier	1
2100B	NM103	Name Last	Last name
2100B	NM104	Name First	First name(s)
2100B	NM105	Name Middle	Middle initial only
2100B	NM106	Name Prefix
2100B	NM107	Name Suffix
2100B	NM108	Identification Code Qualifier	Code Definition 34 Social Security Number
2100B	NM109	Member Identifier	Member’s SSN
2100B	DMG01	Date Time Period Format Qualifier	D8
2100B	DMG02	Member Birth Date	Format is CCYYMMDD
2100B	DMG03	Gender Code	Code Definition F Female M Male
2100B	DMG04	Marital Status Code	All implementation guide codes are usable by HNE
2100C	NM101	Entity Identifier Code	Code Definition 31 Postal Mailing Address
2100C	N301	Address Street Line 1
2100C	N302	Address Street Line 2
2100C	N401	Address City
2100C	N402	Address State
2100C	N403	Address Zip
2100G	NM101	Entity Identifier Code	Code Definition 9K Key Person GD Guardian QD Responsible Party
2100G	NM102	Entity Type Qualifier	1
2100G	NM103	Name Last	Last name
2100G	NM104	Name First	First name(s)
2100G	NM105	Name Middle	Middle initial only
2100G	NM106	Name Prefix
2100G	NM107	Name Suffix
2100G	NM108	Identification Code Qualifier	Code Definition 34 Social Security Number
2100G	NM109	Member Identifier	Member’s SSN
2100G	PER01	Contact Function Code	Code Definition IP Insured Part
2100G	PER03	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100G	PER04	Communication Number
2100G	PER05	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100G	PER06	Communication Number
2100G	PER07	Communication Number Qualifier	Code Definition EM Electronic Mail FA Facsimile HP Home Phone TE Telephone WP Work Phone
2100G	PER08	Communication Number
2100G	N301	Address Street Line 1
2100G	N302	Address Street Line 2
2100G	N401	Address City
2100G	N402	Address State
2100G	N403	Address Zip
2200	DSB01	Disability Type Code	All implementation guide codes are usable by HNE
2200	DTP01	Date/Time Qualifier	All implementation guide codes are usable by HNE
2200	DTP02	Date Time Period Format	D8
2200	DTP03	Disability Begin/End Date	Format is CCYYMMDD
2300	HD01	Maintenance Type Code	All implementation guide codes are usable by HNE
2300	HD03	Insurance Line Code	Code Definition HLT Health HMO Health Maintenance Organization POS Point of Service PPO Preferred Provider Organization
2300	HD04	Plan Coverage Description	*MassHealth use only
2300	DTP01	Date/Time Qualifier	Code Definition 303 Maintenance Effective 348 Benefit Begin 349 Benefit End
2300	DTP02	Date Time Period Format Qualifier	D8
2300	DTP03	Coverage Date	Format is CCYYMMDD
2300	IDC01	Plan Coverage Description	0
2300	IDC02	Identification Card Type Code	Code Definition H Health Insurance
2310	LX01	Assigned Number	1
2310	NM101	Entity Identifier Code	Code Definition P3 Primary Care Provider
2310	NM102	Entity Type Qualifier	Code Definition 1 Person
2310	NM103	Name Last	Last Name
2310	NM104	Name First	First Name(s)
2310	NM105	Name Middle	Middle initial only
2310	NM108	Identification Code Qualifier	Code Definition SV Service Provider Number (internal HNE provider/affiliation#) XX National Provider Identifier (NPI)
2310	NM109	Identification Code
2310	NM110	Entity Relationship Code	All implementation guide codes are usable by HNE
2320	COB01	Payer Responsibility Seq Number	All implementation guide codes are usable by HNE
2320	COB02	Policy Number	COB Policy Number
2320	COB03	COB Code	All implementation guide codes are usable by HNE
2320	REF01	Reference Identification Qualifier	Code Definition 6P Group Number
2320	REF02	Group Number	COB Group Number
2320	DTP01	Date/Time Qualifier	All implementation guide codes are usable by HNE
2320	DTP02	Date Time Period Format Qualifier	D8
2320	DTP03	COB Begin/End Date	Format is CCYYMMDD
2330	NM101	Entity Identifier Code	Code Definition IN Insurer
2330	NM102	Entity Type Qualifier	2
2330	NM103	COB Insurer Name
2330	NM108	Identification Code Qualifier	Code Definition NI National Association of Insurance Commissioners Identification
2330	NM109	NAIC Identification
2330	PER01	Contact Function Code	Code Definition CN General Contact
2330	PER03	Communication Number Qualifier	Code Definition TE Telephone
2330	PER04	COB Contact Phone Number
2000	LS01	Loop Identifier Code	2700
2700	LX01	Assigned Number	A sequential non-negative number starting with 1
2750	N101	Entity Identifier Code	Code Definition 75 Participant
2750	N102	Member Reporting Category Name
2750	REF01	Reference Identification Qualifier	Code Definition XX1 Special Program Code ZZ Mutually Defined
2750	REF02	Member Reporting Cat Ref Id
2750	DTP01	Date/Time Qualifier	Code Definition 007 Effective
2750	DTP02	Date Time Period Format Qualifier	RD8
2750	DTP03	Member Reporting Category Effective Dates	Format is CCYYMMDD-CCYYMMDD
2000	LE01	Loop Identifier Code	2700

Interchange Common Footer Values

Loop	Segment	Element Name	Companion Information
----	SE01	Number of included segments	Total number of segments between and including ST and SE
----	SE02	Transaction Set Control Number	Must match the ST02 control number
----	GE01	Number of Transaction Sets Included	Total number of transaction sets between GS and GE
----	GE02	Group Control Number	Must match the GS06 group header control number
----	IEA01	Number of Included Functional Groups	Total number of functional groups between ISA and IEA
----	IEA02	Interchange Control Number	Must match the ISA13 interchange control number

Compliance Test

All files must pass a stringent TR3 compliance test in order for the 834 transaction to be accepted. This test interprets the “gray box” information in the TR3. A single error will result in the rejection of the entire transaction (ST-SE envelope).

Following the compliance test, the 834 transaction will trigger a 997 Functional Acknowledgment/999 Implementation Acknowledgement, either accepting the transaction or rejecting it with an explanation. The 997 Functional Acknowledgement is available for purchase from Washington Publishing Company at http://www.wpc-edi.com.

For each trading partner and each transaction, we keep track of primary and secondary contacts, including name, address, phone, and e-mail. Please provide this in an e-mail to ecgwsupport@hne.com.

Testing

Before submitting production 834 transactions to Health New England, each trading partner must be tested. Trading partner testing includes HIPAA compliance testing as well as validating the use of conditional, optional, and mutually defined components of the transaction. All trading partners who plan to submit 834 transactions must contact Health New England to discuss the testing process, criteria, and schedule.

A set of testing scenarios has been included here: 5010_834_Test_Scenarios.xls. Not all scenarios are required by all trading partners. For each test file submitted, we would like to receive via secure email a copy of the test scenarios. The tracking sheet should be completed by the trading partner with items filled with enough information to help identify at least one transaction per scenario.