Transcription
The GetInsured State-Based Marketplace (SBM) Platform834 Companion GuideVersion for Release 2019April 12th 2019 GetIns ured 2019 All Rights Res erved.1
1. Introduction41.1. Background42. Business Purpose43. File Naming Conventions54. File Transfer Process65. Acknowledgements and Business Edits65.1. TA1 Interchange Acknowledgment65.2. Functional Acknowledgments76. Subscribers / Dependents77. Uppercase Letters, Special Characters, and Delimiters78. SHOP Versus Individual Transactions89. Control Segments / Envelopes810. The Exchange Business Rules and Limitations910.1. General Business Rules Exceptions910.2. Individual and Shop Market Rate Calculations Exceptions911. The Exchange To Issuer Business Scenarios For 8341011.1. Initial Enrollment Supplemental Instructions1011.2. Cancellation Supplemental Instructions (Subscriber/Enrollment Level)2011.3. Cancellation Supplemental Instructions (Member Level)2211.4. Termination Supplemental Instructions - (Subscriber/Enrollment Level)2411.5. Termination Supplemental Instructions (Member Level)2511.6. Change Transactions - The Exchange to QHP2711.7. Address Changes2811.8. Re-enrollment Supplemental Instructions2811.9. Reinstatement Supplemental Instructions2811.10. Change in Health Coverage2911.11. Change in Circumstance – SHOP only2911.12. Add Member - Same Plan2911.13. Add Member - Different Plan2911.14. Add/Term Dates (mid-month dates)3011.15. Disenroll Member - Same plan3011.16. QLE (Qualifying Life Event) Identifiers3012. Issuer to the Exchange Business Scenarios For 8343112.1. Overview of the Exchange Inbound Processing Rules GetInsured 2019 All Rights Reserved.312
12.2. Enrollment Confirmation / Effectuation Supplemental Ins tructions3212.3. Is s uer Cancellation Supplemental Ins tructions3412.4. Is s uer Termination Supplemental Ins tructions3612.5. Other Trans actions4013. Annual Renewals4113.1. Individual Market4113.1.1. RENP Terms4113.1.2. RENP ADDs4113.1.3. Cross Carrier Renewals4113.1.4. Passive Renewal (Auto Renewal) Terminations for Current Coverage YearEnrollments4213.1.5. Passive Renewal (Auto Renewal) for Next Coverage Year4413.1.6. Renewal Exceptions4713.2. Renewed Enrollment Status4713.3. SHOP Market4814. Monthly Reconciliation4815. Relationship Code s4816. Maintenance Reason Codes4916.1. Term4916.2. Add5016.3. Change5017. Document Control50 GetInsured 2019 All Rights Reserved.3
1. IntroductionThis Companion Guide to the v5010 Accredited Standards Committee (ASC) X12N ImplementationGuides and as s ociated errata adopted under Health Ins urance Portability and Accountability Act(HIPAA) clarifies and s pecifies the data content when exchanging electronically with the Exchange(the Exchange). Trans mis s ions bas ed on this companion guide, us ed in tandem with the v5010ASC X12N Implementation Guides and the CMS Standard Companion Guide Trans action, arecompliant with both ASC X12 s yntax and thos e guides . This guide is intended to conveyinformation that is within the framework of the ASC X12N Implementation Guides adopted for us eunder HIPAA. The Companion Guide is not intended to convey information that in any wayexceeds the requirements or us ages of data expres s ed in the Implementation Guides .This Companion Guide is bas ed on, and mus t be us ed in conjunction with, the ASC X12X12N/005010X220 Type 3 Technical Report (TR3) and its as s ociated A1 addenda. The CompanionGuide clarifies and s pecifies s pecific trans mis s ion requirements for exchanging data with theExchange. The ins tructions in this companion guide conform to the requirements of the TR3, ASCX12 s yntax and s emantic rules and the ASC X12 Fair Us e Requirements . In cas e of any conflictbetween this Companion Guide and the ins tructions in the TR3, the TR3 takes precedence.1.1. BackgroundThe State is creating a health ins urance exchange to comply with the Affordable Care Act (ACA).The Exchange will help individuals and s mall employers s hop for, s elect and enroll in high quality,affordable health plans that fit their needs .In order for the State to run an exchange, it mus t s ubmit enrollment information to CMS accordingto the s tandards they have developed. This s tandard will be the bas is on which the Exchange willexchange information with ins urance carriers . Modifications to the CMS guide will be made whereneces s ary.This Companion Guide contains detailed information about how the Exchange will us e the CMSStandard Companion Guide Trans action v1.7 and the ASC X12 Benefit Enrollment andMaintenance (834) trans action, bas ed on the 005010X220 Implementation Guide and itsas s ociated 005010X220A1 addenda.2. Bus ines s Purpos eThe Health Ins urance Portability and Accountability Act (HIPAA) requires the Exchange and allhealth ins urance carriers to comply with the Electronic Data Interchange (EDI) s tandards for health GetInsured 2019 All Rights Reserved.4
care as es tablis hed by the Department of Health and Human Services (HHS). Thos e compliances tandards are codified in the ASC X12N 5010 vers ion of the Technical Report Type 3 (TR3) foreach trans action type. The Exchange will trade the following health care trans action types : 834 Members hip Enrollments 820 Payment files TA1 Interchange Acknowledgments 999 Functional AcknowledgmentsWhere applicable, the TR3s for thes e trans actions are available electronically from the WPCwebs ite at http://www.wpc-edi.com/. This guide is to be us ed in conjunction with the res pectiveTR3s and is not meant to replace them.3. File Naming ConventionsThe naming conventions for files trans ferred between the Exchange and the ins urance is s uers areas follows ualEnrollments834DailyAuto RenewalTerms for IndividualDirectionI In,O OutI/Ofrom HIOS Issuer ID ID 834 INDV YYYYMMDDHHMMSS .edito HIOS Issuer ID ID 834 INDV YYYYMMDDHHMMSS .ediOto HIOS Issuer ID ID 834 INDV RENTERM YYYYMMDDHHMMSS .edi834DailySHOP EnrollmentsI/O834MonthlyReconciliation forSHOP HOP Enrollments GetInsured 2019 All Rights Reserved.Naming Convention from/to Trading PartnersI/OI/Ofrom HIOS Issuer ID ID 834 SHOP YYYYMMDDHHMMSS .edito HIOS Issuer ID ID 834 SHOP YYYYMMDDHHMMSS .edito HIOS Issuer ID ID 834 RECONSHOP YYYYMMDDHHMMSS .edifrom HIOS Issuer ID ID TA1 834 INDV YYYYMMDDHHMMSS .edito HIOS Issuer ID ID TA1 834 INDV YYYYMMDDHHMMSS .edifrom HIOS Issuer ID ID TA1 834 SHOP YYYYMMDDHHMMSS .edito HIOS Issuer ID ID TA1 834 SHOP YYYYMMDDHHMMSS .edi5
mentsI/O999MonthlyReconciliation forSHOP EnrollmentsIfrom HIOS Issuer ID ID 999 834 INDV YYYYMMDDHHMMSS .edito HIOS Issuer ID ID 999 834 INDV YYYYMMDDHHMMSS .edifrom HIOS Issuer ID ID 999 834 SHOP YYYYMMDDHHMMSS .edito HIOS Issuer ID ID 999 834 SHOP YYYYMMDDHHMMSS .edifrom HIOS Issuer ID ID 999 834 RECONSHOP YYYYMMDDHHMMSS .ediNote: * Daily implies that every day, a maximum of one file/day will be traded.** For Individual Markets pleas e refer to the Exchange-Carrier Reconciliation Guide **4. File Trans fer Proces sFiles created by the Exchange for the carriers will be placed on the Exchange SFTP s erver forcarriers to retrieve. Carriers will place files created by them for the Exchange on the ExchangeSFTP s erver. Additional information on where to drop files , landing zone, etc. will be provided inthe future.5. Acknowledgements and Bus ines s EditsEDI interchanges s ubmitted to the Exchange are proces s ed through compliance edits thatgenerate acknowledgments indicating the portions of data that were accepted vs . rejected. Thos eacknowledgment files are returned to the s ubmitter.5.1. TA1 Interchange Acknowledgment The Exchange expects to receive a TA1 interchange acknowledgment for every outbound820 or 834 file s ent. The Exchange will s end a TA1 acknowledgement for every inbound 820 or 834 file receivedwhen reques ted in the interchange control header. The Exchange will require the reques t for a TA1 in the control header to be in all outboundand inbound 820 and 834 data. The reques t for a TA1 is part of the validation proces s , s oany 820 or 834 data without this reques t will fail validation. GetInsured 2019 All Rights Reserved.6
The Exchange will not s upport TA1 error codes 028-031. The Exchange will only s upport Interchange Acknowledgement Codes "A" and "R".5.2. Functional Acknowledgments The Exchange expects to receive a 999 functional acknowledgment for every functionalgroup in every file s ent. The Exchange will s end 999 functional acknowledgements for every functional group inevery inbound 820 or 834 file received. If a TA1 is rejected, a 999 will not be s ent.6. Subs cribers / DependentsSubs cribers and dependents are s ent as s eparate occurrences of Loop 2000 within the s ame file.The initial enrollment for the s ubs criber mus t be s ent before s ending the initial enrollment for any ofthe s ubs criber’s dependents .7. Uppercas e Letters , Special Characters , andDelimitersAs s pecified in the TR3, the bas ic character s et includes uppercas e letters , digits , s pace, and others pecial characters with the exception of thos e us ed for delimiters . All HIPAA s egments and qualifiers mus t be s ubmitted in UPPERCASE letters only. Delimiters for the trans actions are as follows :CharacterNameDelimiter*AsteriskData Element Separator CaratRepetition Separator:ColonComponent Element Separator TildeSegment Terminator GetInsured 2019 All Rights Reserved.7
To avoid s yntax errors , hyphens , parenthes es and s paces are not recommended to beus ed in values for identifiers .Examples : Tax ID 123654321, SSN 123456789, Phone 80012350108. SHOP Vers us Individual Trans actionsSeparate files will be created for Individual and SHOP enrollments to aid ins urance carriers inproces s ing enrollment trans actions .Multiple Groups / Spons ors will be repres ented in a s ingle 834 but 834s will not be grouped bys pons or.9. Control Segments / EnvelopesTrading partners s hould follow the Interchange Control Structure (ICS) and Functional GroupStructure (GS) guidelines for HIPAA that are located in the HIPAA implementation guides . Thefollowing s ections addres s s pecific information needed by the Exchange in order to proces s theASC X12N/005010X220A1-834 Benefit Enrollment and Maintenance Trans action. This informations hould be us ed in conjunction with the ASC X12N/005010X220 –Benefit Enrollment andMaintenance TR3.Note: in the table below: where “ID” is us ed as part of a value, it is replaced by a given s tate’ss tate abbreviation. For example, in ID, the value for Element ISA06 will be “ID0,” where as in MN,the value for the s ame element will be “MN0” and in NV, the value will be “NV0.”Element NameElementValueAuthorization Information QualifierISA01"00"Security Information QualifierISA03"00"Interchange Sender ID QualifierISA05"ZZ"Interchange Sender IDISA06ID0 for the Exchange outbound to carrierCarrier's Federal Tax ID for carrier inbound to the ExchangeInterchange Receiver ID QualifierISA07"ZZ"Interchange Receiver QualifierISA08" RECEIVERS FEDERAL TAX ID " for the Exchangeoutbound to carrierID0 for carrier inbound to the Exchange GetInsured 2019 All Rights Reserved.8
Interchange AcknowledgmentRequestedISA14"1" for 834/820"0" for TA1/999Functional Identifier CodeGS01"BE"Application Sender’s CodeGS02ID0 for the Exchange outbound to carrierCarrier's for carrier inbound to the ExchangeApplication Receiver’s CodeGS03" RECEIVER'S FEDERAL TAX ID " for the Exchangeoutbound to carrierID0 for carrier inbound to the ExchangeGroup Control NumberGS06The GS06 control number of all outbound 834 data will be setto the same value as the ISA13 control number to allow the999 to reference the appropriate 834 transaction.Version/Release/Industry IdentifierCodeGS08"005010X220A1"10. The Exchange Bus ines s Rules and LimitationsRefer to the CMS Standard Companion Guide Trans action v1.7 for information on bus ines s rulesand limitations . The Exchange will be adhering to thes e rules , with the following exception to theGeneral Bus ines s Rules .10.1. General Business Rules ExceptionsThe Exchange will s end s eparate trans actions if multiple products (Medical & Dental) are s electedfrom the s ame is s uer. The Exchange will not s end thes e as multiple Member Detail Loops at the2000 Member Level like the FFE. Refer to s ection 9.2 of CMS Standard Companion GuideTrans action v1.7 for additional details .The Exchange will leverage the 2750 loop to define cus tom loops (an option the X12 allows tradingpartners ). Thes e cus tom fields provide carriers additional information us eful in the reconciliationcontext. If a carrier is not able to inges t the information contained in the cus tom loop, the carriercan ignore the loops .10.2. Individual and Shop Market Rate Calculations Exceptions The Exchange will not have Family Rated Definitions /Calculations for Individual or SHOPmarkets as it is Per Member per Month. Other Payment Amounts (OTH PAY AMT 1) will not be us ed.Refer to s ection 9.5 of CMS Standard Companion Guide Trans action v1.7 for additional details . GetInsured 2019 All Rights Reserved.9
11. The Exchange To Is s uer Bus ines s Scenarios For83411.1. Initial Enrollment Supplemental InstructionsAn Initial Enrollment trans mis s ion is created by the Exchange and s ent to the QHP Is s uer after anapplication has been determined eligible and a QHP has been s elected.Table or LoopElementIndustry /Element NameHeaderBGNBeginningSegmentBGN08Action CodeDTPFile Effective DateDTP01Date TimeQualifierQTYTransaction SetControl TotalsHeaderHeaderQTY011000A1000B1000CN1Quantity QualifierCodeInstruction2Will transmit to indicate the date the information wasgathered if that date is not the same as ISA09/GS04date303Maintenance EffectiveWill transmit all 3 iterations of this segment.TOTotal. Will transmit to indicate that the valueconveyed in QTY02 represents the total number ofINS segments in this ST/SE set.DTDependent Total. Will transmit to indicate that thevalue conveyed in QTY02 represents the totalnumber of INS segments in this ST/SE set withINS01 "N"ETEmployee Total (Subscribers). Will transmit toindicate that the value conveyed in QTY02represents the total number of INS segments in thisST/SE set with INS01 "Y"24SHOP Market. (SHOP Market identifies the employergroup.)Sponsor NameN103IdentificationCode QualifierN1PayerN103IdentificationCode QualifierN1TPA/Broker Name GetInsured 2019 All Rights Reserved.FIIndividual Market. (Individual Market identifies thesubscriber from the enrollment group, unless thesubscriber is under-aged. If the subscriber is underaged, identifies the responsible person.)Identifies the issuer of the QHPFIWill transmit the Issuer Federal Tax IDWill transmit if a broker was involved in theenrollment10
1100C200020002000N101Entity IdentifierCodeN102Broker NameN103IdentificationCode QualifierN104TPA/BrokerIdentificationCodeWill transmit the broker's federal tax id when a brokerwas involved in the enrollmentACTTPA/BrokerAccountInformationWill transmit if a broker was involved in theenrollmentACT01TPA/BrokerAccountInformationWill transmit the broker's NPN if a broker wasinvolved in the enrollmentINSMember ntenanceType Code021INS04MaintenanceReason CodeECINS08EmploymentStatus Qualifier GetInsured 2019 All Rights Reserved.BOFISee Section 14 for list of codes0FThe Exchange Assigned ID of the subscriber(member id of subscriber).Individual Market: If enrollment is for dependentsonly, the youngest member will be the subscriber.SHOP Health Plans - This will always be theemployee (employee case id)Pediatric Dental: If enrollment is for dependents only,the youngest member will be the subscriber.17Will transmit when the Exchange Assigned MemberID will be conveyed in REF02.1LWill transmit when the Exchange Assigned Policy IDwill be conveyed in REF026OPayment Transaction ID11
2100ANM1Member NameNM109Member IdentifierThe SSN is allowed for this Federally administeredprogram based on confidentiality regulations. Willtransmit the member's SSN when known.Will transmit three communication contacts --- homephone, work phone, cell phone, or email address --when the information is available.Only sent for the subscriber if the subscriber is thehousehold contact.Communication contacts will be sent in the followingorder:1st --- Primary Phone ("TE")2nd --- Secondary Phone ("AP")3rd --- Preferred Communication Method ("EM" foremail). If no preferred communication method ischosen, the 3rd communication contact will not ember City,State, ZIP CodeN406Location IdentifierDMGMemberDemographicsDMG02Member BirthDateDMG03Gender CodeDMG04Marital StatusCodeWill be transmitted when available for dep and subloops. Will support full compliment of marital statuscodes from FFMDMG0503Race or EthnicityCodeWill transmit when available.DMG06Citizenship StatusCodeThis segment will never be transmitted for theExchange.2100AECEmploymentClassThis segment will never be transmitted for theExchange.2100AICMMember IncomeThis segment will never be transmitted for theExchange.2100AAMTMember PolicyAmountsThis segment will never be transmitted for theExchange.2100AHLHMember HealthInformationHLH01Health RelatedCodeLUIMemberLanguage2100A2100A GetInsured 2019 All Rights Reserved.Will transmit FIPS HUB 6-4 County of Residencewhen available.TNTobacco UseNoneTransmission of this information is required whenknown and allowed. Spoken and Written languageinformation will be transmitted when known.12
Will only be sent for subscriber when the subscriberis the household contact.2100ALUI01IdentificationCode QualifierLDNISO Z39.53 Language CodesLUI02Language CodeengspaOnly English or Spanish will be sent.LUI04Language UseIndicator6Written Language7Spoken Language2100BIncorrect MemberName LoopThis loop does not apply to initial enrollments.2100DMemberEmployer LoopThis loop will never be transmitted for the Exchange.2100EMember SchoolLoopThis loop will never be transmitted for the Exchange.2100FCustodial ParentLoopThis loop will never be transmitted for the Exchange.2100GResponsiblePerson LoopThe Responsible Person loop may both betransmitted for an enrollment.This is the primary contact for the household and willbe sent for every member including the subscriber.NM1ResponsiblePersonNM101Entity IdentifierCodeNM109Responsible PartyIdentifierThe SSN is allowed for this Federally administeredprogram based on confidentiality regulations. Willtransmit the SSN when known.ResponsiblePersonCommunicationNumbersWill transmit three communication contacts --- homephone, work phone, cell phone, or email address --when the information is available.Communication contacts will be sent in the followingorder:1st --- Primary Phone ("TE")2nd --- Secondary Phone ("AP")3rd --- Preferred Communication Method ("EM" foremail or "BN" for a phone number for receiving textmessages). If no preferred communication method ischosen, the 3rd communication contact will not besent.Note: Email (EM) will be transmitted only if consumerhas elected email as their Preferred CommunicationMethod.2100HDrop-Off LocationLoopThis loop will never be transmitted for the Exchange.2200DisabilityInformation LoopThis loop will never be transmitted for the Exchange.2100G2100G2300PERHDQDWill transmit "QD" when sent. "S1" will never be sent.Health Coverage GetInsured 2019 All Rights Reserved.13
23002300HD03Insurance LineCodeDTPHealth CoverageDatesDTP03Date TimeQualifierREFREF01HLTDENWill transmit coverage information for the qualifiersshown, as applicable.348The Enrollment Begin Date will be transmitted349The Enrollment Period End
(the Exchange). Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides and the CMS Standard Companion Guide Transaction, are compliant with both ASC X12 syntax and those
