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Benefit Enrollment and Maintenance
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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]
Benefit Enrollment and Maintenance
Version Number: 2.0
October 1, 2010
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products and services to the recipient. Any other use, copying or distribution without the express written permission of
UnitedHealthGroup is prohibited.
Page 2 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
Benefit Enrollment and Maintenance
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
Page 3 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.
Benefit Enrollment and Maintenance
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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
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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.
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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.
Benefit Enrollment and Maintenance
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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.
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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.
Benefit Enrollment and Maintenance
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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.
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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.
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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)
Benefit Enrollment and Maintenance
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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.
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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.
Benefit Enrollment and Maintenance
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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
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Page 15 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
Benefit Enrollment and Maintenance
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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
2 This element contains the qualifier indicating whether the
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
2 This element contains the qualifier indicating whether the
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
Benefit Enrollment and Maintenance
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
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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
77 2100A EC02 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
2 Contains the employment class code of the employee
Benefit Enrollment and Maintenance
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
Page 18 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
77 2100A EC03 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
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
Benefit Enrollment and Maintenance
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
Page 19 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:
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products and services to the recipient. Any other use, copying or distribution without the express written permission of
UnitedHealthGroup is prohibited.
Page 20 of25
Benefit Enrollment and Maintenance UnitedHealthcare®
Healin health care. To ether:"
Benefit Enrollment and Maintenance
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
Page 21 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
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Page 22 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].
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products and services to the recipient. Any other use, copying or distribution without the express written permission of UnitedHealthGroup is prohibited.
Page 23 of 25
Benefit Enrollment and Maintenance
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.
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Page 24 of 25
Benefit Enrollment and Maintenance
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.
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Page 25 of 25
Benefit Enrollment and Maintenance
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.