delta dental of arizona · 2013-12-03 · delta dental companion guide 3 october 1, 2010....

DELTA DENTAL COMPANION GUIDE

October 1, 2010. 005010.5.3

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Delta Dental of Arizona HIPAA Transaction

Standard Companion Guide

Refers to the X12N Implementation Guide

005010X220: 834 – Benefit Enrollment and

Maintenance

Companion Guide Version Number: 5.3


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EDITOR’S NOTE:

This Companion Guide is a work in-progress. Information found here may change over

time. Delta Dental of Arizona reserves the right to make changes to this Companion

Guide.


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Table of Contents

Introduction 4

General EDI Terminology 5

ASC X12 Nomenclature 6

Header Segments 7

Trailer Segments 9

Data Clarifications for the 834 Transaction Set 10

Preferred Values for Elements 10

Segments Not Used by Delta Dental 17


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Introduction

This document is the property of Delta Dental of Arizona and is intended to provide guidance in

implementing the ANSI ASC X12N Version 5010 Benefit Enrollment and Maintenance – 834

transaction. This ASC X12N 834 format is mandated by the Health Insurance Portability and

Accountability Act (HIPAA). This transaction is used to transfer enrollment information electronically

from the sponsor of the insurance coverage to a healthcare payer. Use of the 5010 version of the X12

standard is required by federal law. The compliance date for use of this standard is January 1, 2012.

There are required, as well as situational loops that each user must take into consideration in

determining the appropriate use for their transactions. It is recommended that each user develop

relevant business scenarios for their business uses of the 834, as the use of this transaction can vary

from user to user. As guidance, please refer to the Business Scenarios developed by ASC X12N

Insurance Subcommittee for the 834 transaction. These are located at:

www.wpc-edi.com

This document is based on the implementation standard of the ASC X12N Benefit Enrollment and

Maintenance – 834. It is meant to be a companion document and not a replacement for the ASC X12

834 implementation guide. Specific instructions contained in this document are provided for

clarification purposes only and should be used in conjunction with the applicable HIPAA

Implementation Guides published by Washington Publishing Company.

If you would like to view the implementation guide and the ASC X12 standards, please refer to the

documents published by the Washington Publishing Company for the ASC X12N Insurance

Subcommittee. The website for purchasing these documents is:

Store.x12.org

HIPAA regulations allow users to submit changes to the electronic transactions formats. To request

changes for consideration to the ASC X12 standards, please contact the HIPAA Designated Standards

Maintenance Organizations website at:

www.hipaa-dsmo.org

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

http://store.x12.org/

http://www.hipaa-dsmo.org/


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General EDI Terminology

A listing of terms commonly used throughout the HIPAA regulations and the EDI transactions is

available from WEDI. The website is:

www.wedi.org

Go to the Resources, Select HIPAA Resources and it will be found under the other HIPAA resources

section.

ANSI X12 834 v5010 – HIPAA standardized ANSI X12 transaction format for benefit enrollment and

maintenance.

Basic Character Set – The basic character set includes those characters selected from the uppercase

letters, digits, space, and specified characters such as: A…Z | 0…9 | ! | “ | & | ‘ | ( | ) | * | + | , | - | . | / | :

| ; | ? | = | space.

Data Segment – Corresponds to a record in data processing terminology. Consists of logically related

data elements in a defined sequence (defined by X12). Each segment begins with a segment identifier,

which is not a data element and one or more related data elements, which are preceded by a data

element separator. Each segment ends with a segment terminator.

Data Element – Corresponds to a field in data processing. They are assigned a unique reference

number. Each element has a name, description, type, minimum length and maximum length. The

length of an element is the number of character positions used.

EDI – An acronym for Electronic Data Interchange.

Electronic Data Interchange – the application-to-application transfer of key business information

transacted in a standard format using a computer-to-computer communications link.

Implementation guides – Documents that provide standardized data requirements and content as the

specifications for consistent implementation of a standard transaction set. HIPAA implementation

guides are published by the Washington Publishing Company on their website: www.wpc-edi.com.

Interface – The point at which two systems connect to pass data.

Loops – Loops are groups of semantically related segments. Data segment loops may be unbounded or

bounded.

Trading partners – Entities that exchange electronic data files. Agreements are sometimes made

between the partners to define the parameters of the data exchange and simplify the implementation

process.

http://www.wedi.org/



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X12 Transaction Set – A transaction set is considered one business document which is composed of a

transaction set header control segment, one or more data segments, and a transaction set trailer control

segment.

X12N – An Accredited Standards Committee (ASC) commissioned by the American National

Standards Institute (ANSI) to develop standards for Electronic Data Interchange (EDI). While X12

indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing EDI

standards for the insurance industry.

ASC X12 Nomenclature

The ASC X12 Nomenclature guide is a useful reference in understanding the details of the ASC X12

transactions. This includes hierarchical structure of the ASC X12 transactions, general definitions and

concepts, relations among control segments, functional groups, and HL structures. The ASC X12

Nomenclature guide is the same for all transactions. To review this guide, please refer to the website:

www.wpc-edi.com



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Header Segments

Interchange Control Header The ISA segment is the Interchange Header Segment. This segment identifies the sender and

receiver for each transaction. This segment also identifies the delimiters used throughout the

file.

Please use these values when sending the ISA segment:

Page # Loop Id Reference Name Length Value

C.4 n/a ISA01 Authorization Information

Qualifier

2/2 00

C.4 n/a ISA02 Authorization Information 10/10 Fill with 10 Spaces

C.4 n/a ISA03 Security Information Qualifier 2/2 00

C.4 n/a ISA04 Security Information 10/10 Fill with 10 Spaces

C.4 n/a ISA05 Interchange ID Qualifier 2/2 Groups ID qualifier

C.4 n/a ISA06 Interchange Sender ID 15/15 Group’s Tax ID or similar number (For

TPA’s, this must be a unique number for

each group that you send)

C.4 n/a ISA07 Interchange ID Qualifier 2/2 30

C.4 n/a ISA08 Interchange Receiver ID 15/15 860274899

C.6 n/a ISA15 Interchange Usage Indicator 1/1 T = Test for all test files

P = Production for all production files

For all other ISA elements, please refer to the HIPAA-AS implementation Guides for specific

instructions.

Functional Group Header The GS segment indicates the beginning of a functional group and provides control

information.

Please use these values when sending the GS segment:


C.7 n/a GS02 Application Sender’s Code 2/15 Use your Sender Id or the same value as

ISA06

C.7 n/a GS03 Application Receiver’s Code 2/15 DDAZ

For all other GS elements please refer to the HIPAA-AS implementation Guides for specific

instructions.

Transaction Set Header The ST segment indicates the start of a transaction set and assigns a control number.

For all ST elements please refer to the HIPAA-AS implementation Guides for specific

instructions.


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Sponsor Name - This segment identifies the sponsor.

Please use these values when sending the N1 segment in the 1000A loop:


39 1000A N101 Entity Identifier Code 2/3 P5

39 1000A N102 Name 1/60 Group or Employer’s Name

40 1000A N103 Identification Code Qualifier 1/2 24 or FI

40 1000A N104 Identification Code 2/80 Employer’s ID Number or Federal Tax ID

Payer - This segment identifies the payer.

Please use these values when sending the N1 segment in the 1000B loop:


41 1000B N101 Entity Identifier Code 2/3 IN

41 1000B N102 Name 1/60 DELTA DENTAL OF ARIZONA

42 1000B N103 Identification Code Qualifier 1/2 FI

42 1000B N104 Identification Code 2/80 860274899

TPA/Broker Name - This segment identifies the TPA/Broker if involved.

Please use these values when sending the N1 segment in the 1000C loop:


43 1000C N101 Entity Identifier Code 2/3 BO for Broker, TV for TPA

43 1000C N102 Name 1/60 Broker or TPA Name

44 1000C N103 Identification Code Qualifier 1/2 FI

44 1000C N104 Identification Code 2/80 Broker or TPA Federal Tax ID


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Trailer Segments

Interchange Control Trailer The IEA segment identifies the end of an interchange of zero or more functional groups and

interchange-related control segments and is the last segment within the transaction set.

For all IEA elements please refer to the HIPAA-AS Implementation Guides for specific

instructions.

Functional Group Trailer

The GE segment indicates the end of a functional group and provides control information.

For all GE elements please refer to the HIPAA-AS implementation Guides for specific

instructions.

Transaction Set Trailer The SE segment indicates the end of a transaction set and provides the count of transmitted

segments.

For all SE elements please refer to the HIPAA-AS implementation Guides for specific

instructions.


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Data Clarifications for the 834 Transaction Set

Delta Dental would prefer to receive the basic character set

Preferred Values for Elements

Page # Loop Id Reference Name Codes Length Notes/Comments

48 2000 INS01 Yes/No Condition Response

Code – Insured Indicator

Y – Subscriber

N - Dependent

1/1

48 2000 INS02 Individual Relationship Code The preferred values for this are:

01 – Spouse

09 – Adopted Child

10 – Foster Child

15 – Ward

17 – Stepson or Stepdaughter

18 – Self (Subscriber)

19 – Child

23 – Sponsored Dependent

25 – Ex-Spouse

53 – Life Partner

2/2

49 2000 INS03 Maintenance Type Code 001 – Change

021 – Addition

024 – Cancellation or

termination

025 – Reinstatement

030 – Audit or Compare

3/3

49 2000 INS05 Benefit Status Code The preferred values for this are:

A – Active

C – COBRA

1/1


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52 2000 INS07 COBRA Qualifying Event

Code

1 – Termination

2 – Reduction of work hours

3 – Medicare

4 – Death

5 – Divorce

6 – Separation

7 – Ineligible Child

8 – Bankruptcy of Retired

Employee’s former employer

9 – Layoff

10 – Leave of Absence

1/2 Required if member is enrolled in COBRA

52 2000 INS08 Employment Status Code AO – Active Military – Overseas

AU – Active Military – USA

FT – Full-time active employee

L1 – Leave of Absence

PT – Part-time Active Employee

RT – Retired

TE – Terminated

2/2 Required for subscriber

53 2000 INS09 Student Status Code The preferred values for this are:

F – Full-time

N – Not a Student

P – Part-time will be treated as

“Not a Student”

1/1

53 2000 INS10 Yes/No Condition or

Response – Handicap

Indicator

N – No individual is not

handicapped

Y – Yes individual is

handicapped

1/1

54 2000 INS12 Date Time Period 1/35 Date of death of the subscriber/dependent

55 2000 REF01 Reference Identification

Qualifier

0F – Subscriber Number 2/3 Required field for all members.

55 2000 REF02 Reference Identification 1/50 The Social Security number of the subscriber

or the Employee ID number supplied by the

employer. If both are required, use NM109

for the SSN. If SSN is required but EIN is

optional, use REF01 = DX for the EIN.

Numeric values only.


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Qualifier

1L – Group Number 2/3 This should only be used for Dental only or

Vision only groups. Groups with both should

send in the 2300 loop.

56 2000 REF02 Reference Identification 1/50 The 18 digit Group Number assigned by Delta

Dental

59 2000 DTP01 Date/Time Qualifier 336 – Employment Begin (Hire Date)

350 – Education Begin (Student Start Date)

357 – Eligibility End (Termination

Date/Last Day of Coverage)

3/3

60 2000 DTP03 Date Time Period 1/35 Status Information Effective Date

62 2100A NM101 Entity Identifier Code 74 – If sending corrected identifier

information on already enrolled member

IL - If enrolling new member or updating

member with no change in identifying

information

2/3

63 2100A NM102 Entity Type Qualifier 1 – Person 1/1

63 2100A NM103 Name Last or Organization

Name

1/60 Member Last Name

63 2100A NM104 Name First 1/35 Member First Name

63 2100A NM105 Name Middle 1/25 Send if supplied

Member Middle Name

63 2100A NM107 Name Suffix 1/10 Send if supplied

Member Name Suffix

64 2100A NM108 Identification Code Qualifier 34 – Social Security Number 1/2 Send when required by X12 syntax

64 2100A NM109 Identification Code 2/80 Subscriber’s Social Security Number

65 2100A PER01 Contact Function Code IP – Insured Party 2/2 Send if supplied

65 2100A PER03/05/

07

Communication Number

Qualifier

EM – Electronic Mail (Email)

HP – Home Phone Number

TE – Telephone

WP – Work Phone Number

2.2 Send if supplied

65 2100A PER04/06/

08

Communication Number Insert the email or phone number here.

Please do not include any formatting in the

phone number. i.e. Send the phone number

as 5554443333

Send if supplied


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68 2100A N301 Address Information 1/55 Required when enrolling subscriber, when

enrolling a dependent and the dependent’s

address is different from the subscriber’s

and when changing a member’s address.

Member Address Line 1

Please note that Delta Dental only stores the

first 30 characters of this field.

68 2100A N302 Address Information 1/55 Required if second address line exists


Please note that Delta Dental only stores the

first 30 characters of this field.

69 2100A N401 City Name 2/30 Member City Name

69 2100A N402 State or Province Code 2/2 Member State Code

70 2100A N403 Postal Code 3/15 Member Postal Zone or Zip Code

70 2100A N404 Country Code 2/3 Required if country is not USA

71 2100A DMG02 Date Time Period 1/35 Required element. If not available, use

Delta Dental’s default - 19010101

Member Birth Date

72 2100A DMG03 Gender Code F – Female

M – Male

U – Unknown

1/1

86 2100B NM101 Entity Identifier Code 70 – Prior Incorrect Insured 2/3

87 2100B NM102 Entity Type Qualifier 1 – Person 1/1

87 2100B NM103 Name Last or Organization

Name

1/60 Incorrect Member Last Name

87 2100B NM104 Name First 1/35 Incorrect Member First Name

87 2100B NM105 Name Middle 1/25 Send if supplied Incorrect Member Middle Name

87 2100B NM107 Name Suffix 1/10 Send if supplied

Incorrect Insured’s Name Suffix

87 2100B NM108 Identification Code Qualifier 34 – Social Security Number 1/2 Send when required by X12 syntax

88 2100B NM109 Identification Code 2/80 Incorrect Subscriber’s Social Security

Number

90 2100B DMG02 Date Time Period 1/35 Required when there is a change to

previous demographic information

Incorrect Member Birth Date


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90 2100B DMG03 Gender Code F – Female

M – Male

U – Unknown

1/1 Incorrect Member Gender Code

92 2100C NM101 Entity Identifier Code 31 – Postal Mailing Address 2/3 Send if mailing address is different from

residence address, dependent’s address is

different from the subscriber’s, or changing

member’s address

92 2100C NM102 Entity Type Qualifier 1 – Person 1/1

94 2100C N301 Address Information 1/55 Member Address Line 1

94 2100C N302 Address Information 1/55 Required if second address line exist


95 2100C N401 City Name 2/30 Member City Name

95 2100C N402 State or Province Code 2/2 Member State Code

96 2100C N403 Postal Code 3/15 Member Postal Zone or Zip Code

96 2100C N404 Country Code 2/3 Required if country is not USA

106 2100E NM101 Entity Identifier Code M8 – Educational Institution 2/3

106 2100E NM102 Entity Type Qualifier 2 – Non-Person Entity 1/1

107 2100E NM103 Name Last or Organization

Name

1/60 School Name

140 2300 HD01 Maintenance Type Code 001 – Change

002 – Delete (incorrect coverage

record)

021 – Addition

024 – Cancellation/Termination

025 – Reinstatement

026 – Correction

030 – Audit or Compare

032 – Employee Information

Not Applicable

3/3 Required when enrolling a new member or

when adding, updating or removing

coverage

141 2300 HD03 Insurance Line Code DEN – Dental

VIS – Vision

2/3 Include a 2300 loop for each line of

insurance present.


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142 2300 HD05 Coverage Level Code For 2 Tier:

EMP – Employee Only (S)

FAM – Family (F)

For 3 Tier:


E1D – Employee and One Dependent (Child) (D)

ESP – Employee and Spouse (D)

E6D – Employee and Two or More Dependents (M)

For 4 Tier:


ECH – Employee and Children (K)

ESP – Employee and Spouse (P)

FAM – Family (F)

For Composite:

FAM – Composite (T)

3/3 The preferred values are based on

the group contract.

143 2300 DTP01 Date/Time Qualifier 303 – Maintenance Effective (Change Date)

348 – Benefit Begin (Effective Date)

349 – Benefit End (Termination Date/Last Day of

Coverage)

3/3 Required when enrolling a member

or when there is a change to the

dates.

144 2300 DTP03 Date Time Period 1/35 Coverage Period


Qualifier

1L – Group Number 2/3 This should only be used for groups

with both Dental and Vision Groups

with only Dental or Only vision

should send in the 2000 loop.

147 2300 REF02 Reference Identification 1/50 The 18 digit Group Number assigned

by Delta Dental

164 2320 COB01 Payer Responsibility

Sequence Number Code

P – Primary

S – Secondary

T – Tertiary

1/1 Provide if available

164 2320 COB02 Reference Identification 1/50 Insured Group or Policy Number

164 2320 COB03 Coordination of Benefits

Code

1 – Coordination of Benefits

6 – No Coordination Of Benefits

1/1


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N/A 2500 FSA01 Maintenance Type Code 030 – Audit or Compare 3/3 Loop 2500 is for Flexible Spending

Plans only. If FSA does not apply

for a subscriber, omit this loop. If

the loop is present, FSA is present.

N/A 2500 FSA02 Flexible Spending Account

Selection Code

H – Healthcare 1/1

For all other elements, please refer to the HIPAA-AS implementation Guides for specific instructions.


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Segments Not Used by Delta Dental

Loop Segment ID Name Page Loop Segment ID Name Page

2100A EC Employment Class 76 2330 N3 Coordination of Benefits Related Entity Address 171

2100A ICM Member Income 79 2330 N4 Coordination of Benefits City, State, Zip 172

2100A AMT Member Policy Amounts 81 2330 PER Administrative Communications Contact 174

2100A HLH Member Health Information 82 2330 LS Additional Reporting Categories 176

2100A LUI Member Language 84 2710 LX Member Reporting Categories 177

2100D NM1 Member Employer 97 2750 N1 Reporting Category 178

2100D PER Member Employer Communications Numbers 100 2750 REF Reporting Category Reference 179

2100D N3 Member Employer Street Address 103 2750 DTP Reporting Category Date 181

2100D N4 Member Employer City, State, Zip 104 2750 LE Additional Reporting Categories Loop Termination 183

2100E PER Member School Communications Numbers 108

2100E N3 Member School Street Address 111

2100E N4 Member School City, State, Zip 112

2100F NM1 Custodial Parent 114

2100F PER Custodial Parent Communications Numbers 117

2100F N3 Custodial Parent Street Address 120

2100F N4 Custodial Parent City, State, Zip 121

2100G NM1 Responsible Person 123

2100G PER Responsible Person Communications Numbers 126

2100G N3 Responsible Person Street Address 129

2100G N4 Responsible Person City, State, Zip 130

2200 DSB Disability Information 137

2200 DTP Disability Eligibility Dates 139

2300 AMT Health Coverage Policy 145

2300 IDC Identification Card 150

2310 LX Provider Information 152

2310 NM1 Provider Name 153

2310 N3 Provider Address 156

2310 N4 Provider City, State, Zip Code 157

2310 PER Provider Communications Numbers 159

2310 PLA PCP Change Reason 162

2320 REF Additional Coordination of Benefits Identifiers 166

2320 DTP Coordination of Benefits Eligibility Dates 168

2330 NM1 Coordination of Benefits Related Entity 169