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Ford 834 Implementation Guidelines
X12 Implementation Guidelines
For Outbound
Benefit Enrollment and Maintenance
v004010
(834O)
Ford Motor Company
fd834O (004010) July 21, 2006 1
834 Benefit Enrollment and Maintenance
DRAFT
Functional Group ID=BE
Introduction:
This Draft Standard for Trial Use contains the format and establishes the data contents of the Benefit Enrollment and
Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used to establish communication between the sponsor of the insurance product and the
payer. Such transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of
this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor
can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that
pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health
maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid,
Champus, etc.), or an entity that may be contracted by one of these former groups. For the purpose of the 834
transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those
covered by the sponsor if the sponsor does not elect to perform this function itself.
Table 1 - Header:
Pos. Seg. Req. Loop Notes and
No. ID Name Des. Max.Use Repeat Comments
Must Use 010 ST Transaction Set Header M 1 Must Use 020 BGN Beginning Segment M 1
030 REF Transaction Set Policy Number O 1
040 DTP File Effective Date O >1
LOOP ID - 1000A 1 Must Use 070 N1 Sponsor Name M 1 n1
LOOP ID - 1000B 1 Must Use 070 N1 Payer M 1 n2
LOOP ID - 1000C 2 Not Used 070 N1 TPA/Broker Name X 1 n3
LOOP ID - 1100C 1 Not Used 120 ACT TPA/Broker Account Information X 1
Table 2 - Detail:
Pos. Seg. Req. Loop Notes and
No. ID Name Des. Max.Use Repeat Comments
LOOP ID - 2000 >1 Must Use 010 INS Member Level Detail M 1 n4 Must Use 020 REF Subscriber Number M 1 n5 Not Used 020 REF Member Policy Number X 1 n6
020 REF Member Identification Number O 6 n7 Not Used 020 REF Prior Coverage Months X 1 n8
025 DTP Member Level Dates O 20
LOOP ID - 2100A 1 Must Use 030 NM1 Member Name M 1
040 PER Member Communications Numbers O 1
050 N3 Member Residence Street Address O 1
060 N4 Member Residence City, State, Zip Code O 1 Must Use 080 DMG Member Demographics M 1
110 ICM Member Income O 1
120 AMT Member Policy Amounts O 1
Ford Motor Company
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Not Used 130 HLH Member Health Information X 1 Not Used 150 LUI Member Language X 5
LOOP ID - 2100B 1
030 NM1 Incorrect Member Name O 1 Not Used 080 DMG Incorrect Member Demographics X 1
LOOP ID - 2100C 1 Not Used 030 NM1 Member Mailing Address X 1 Not Used 050 N3 Member Mail Street Address X 1 Not Used 060 N4 Member Mail City, State, Zip X 1
LOOP ID - 2100D 3 Not Used 030 NM1 Member Employer X 1 Not Used 040 PER Member Employer Communications Numbers X 1 Not Used 050 N3 Member Employer Street Address X 1 Not Used 060 N4 Member Employer City, State, Zip X 1
LOOP ID - 2100E 3 Not Used 030 NM1 Member School X 1 Not Used 040 PER Member School Communications Numbers X 1 Not Used 050 N3 Member School Street Address X 1 Not Used 060 N4 Member School City, State, Zip X 1
LOOP ID - 2100F 1
030 NM1 Custodial Parent O 1 Not Used 040 PER Custodial Parent Communications Numbers X 1
050 N3 Custodial Parent Street Address O 1
060 N4 Custodial Parent City, State, Zip O 1
LOOP ID - 2100G 1 Not Used 030 NM1 Responsible Person X 1 Not Used 040 PER Responsible Person Communications Numbers X 1 Not Used 050 N3 Responsible Person Street Address X 1 Not Used 060 N4 Responsible Person City, State, Zip X 1
LOOP ID - 2200 1 Not Used 200 DSB Disability Information X 1 n9 Not Used 210 DTP Disability Eligibility Dates X 2
LOOP ID - 2300 99 Must Use 260 HD Health Coverage M 1 Must Use 270 DTP Health Coverage Dates M 4 Not Used 280 AMT Health Coverage Policy X 4
290 REF Health Coverage Policy Number O 3 Not Used 300 IDC Identification Card X 10
LOOP ID - 2310 30 Not Used 310 LX Provider Information O 1 n10 Not Used 320 NM1 Provider Name M 1 n11 Not Used 360 N4 Provider City, State, Zip Code X 1 Not Used 370 PER Provider Communications Numbers X 2 Not Used 395 PLA PCP Change Reason X 1
LOOP ID - 2320 5
400 COB Coordination of Benefits O 1
405 REF Additional Coordination of Benefits Identifiers O 5 Not Used 410 N1 Other Insurance Company Name X 1
450 DTP Coordination of Benefits Eligibility Dates O 2
Must Use 690 SE Transaction Set Trailer M 1
Ford Motor Company
fd834O (004010) July 21, 2006 3
Transaction Set Notes
1. At least one iteration of loop 1000 is required to identify the sender or receiver.
2. At least one iteration of loop 1000 is required to identify the sender or receiver.
3. At least one iteration of loop 1000 is required to identify the sender or receiver.
4. A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A
Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore
entitled to benefits. Subscriber information must come before dependent information. The INS segment
is used to note if information being submitted is subscriber information or dependent information.
5. The REF segment is required to link the dependent(s) to the subscriber.
6. The REF segment is required to link the dependent(s) to the subscriber.
7. The REF segment is required to link the dependent(s) to the subscriber.
8. The REF segment is required to link the dependent(s) to the subscriber.
9. The DSB loop may only appear for the Subscriber.
10. Loop 2310 contains information about the primary care providers for the subscriber or the dependent,
and about the beneficiaries of any employer-sponsored life insurance for the subscriber.
11. Either NM1 or N1 will be included depending on whether an individual or organization is being
specified.
12. The interchange control headers set the actual values of the data element separator, sub element
separator, and the data segment terminator for this interchange. It is expected that these values be read
dynamically by an EDI translator and are defined here for informational purposes only. In the segment
diagram below the data element separator is represented by the "~" character (ASCII Hex '7E' Decimal
'126'). The Sub Element Separator is represented by the "<" character (ASCII Hex '3C' Decimal '60').
The Segment Terminator appears graphically as a "." or a small box (ASCII Hex '1C' Decimal '28'). For
the purposes of creating this document a period was used as the segment terminator and should not be
interpreted as the literal value for a segment terminator. The values are used consistently from the header
through the interchange trailer. Refer to the Ford Motor Company "X12 Interchange" document for a
full representation of the interchange enveloping structures.
Ford Motor Company
fd834O (004010) July 21, 2006 4
Segment: ST Transaction Set Header
Position: 010
Loop:
Level: Heading:
Usage: Mandatory
Max Use: 1
Purpose: To indicate the start of a transaction set and to assign a control number
Syntax Notes:
Semantic Notes: 1 The transaction set identifier (ST01) used by the translation routines of the
interchange partners to select the appropriate transaction set definition (e.g., 810
selects the Invoice Transaction Set).
Comments:
Notes: Example: ST~834~0001.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> ST01 143 Transaction Set Identifier Code M ID 3/3 Code uniquely identifying a Transaction Set
834 Benefit Enrollment and Maintenance
>> ST02 329 Transaction Set Control Number M AN 4/9 Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. For example, start with
the number 0001 and increment from there. This number must be unique
within a specific group and interchange, but the number can repeat in other
groups and interchanges.
Ford Motor Company
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Segment: BGN Beginning Segment
Position: 020
Loop:
Level: Heading:
Usage: Mandatory
Max Use: 1
Purpose: To indicate the start of a transaction set
Syntax Notes: 1 If BGN05 is present, then BGN04 is required.
Semantic Notes: 1 BGN02 is the transaction set reference number.
2 BGN03 is the transaction set date.
3 BGN04 is the transaction set time.
4 BGN05 is the transaction set time qualifier.
5 BGN06 is the transaction set reference number of a previously sent transaction
affected by the current transaction.
Comments:
Notes: Example: BGN~00~2001072320101700~20010723~201017~ES~~~2.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> BGN01 353 Transaction Set Purpose Code M ID 2/2 Code identifying purpose of transaction set
00 Original
Used to indicate that this is the first time Daily or
Monthly change transactions are being sent.
Daily Change N102 will contain "PEOPLESOFT
DAILY CHANGE", N101=P5
22 Information Copy
Used to indicate that the data is to be used to conduct an
audit. Represents a Full Positive file.
N102 will contain "PEOPLESOFT FULL POS",
N101=P5
>> BGN02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Transaction set reference number assigned by the transaction builder to
uniquely identify this occurrence of the transaction for future reference. The
reference number is derived from run date (format CCYYMMDD) and run
time (HHMMSSDD).
>> BGN03 373 Date M DT 8/8 Date expressed as CCYYMMDD
Identifies the date the submitter created the file. Represents run date or date
mailboxed
>> BGN04 337 Time M TM 4/8 Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-
59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds
are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Used to identify the time of day the submitter created the file. Represents run
time or time mail boxed. Format is HHMM.
BGN05 623 Time Code O ID 2/2
Code identifying the time. In accordance with International Standards
Organization standard 8601, time can be specified by a + or - and an indication
in hours in relation to Universal Time Coordinate (UTC) time; since + is a
restricted character, + and - are substituted by P and M in the codes that follow
ES Eastern Standard Time
Ford Motor Company
fd834O (004010) July 21, 2006 6
X BGN06 127 Reference Identification O AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X BGN07 640 Transaction Type Code O ID 2/2
Code specifying the type of transaction
Refer to 004010 Data Element Dictionary for acceptable code values.
>> BGN08 306 Action Code M ID 1/2 Code indicating type of action
2 Change (Update)
Value of '2' used to denote a daily activity file. Used to
identify a transaction of additions, terminations and
changes to the current enrollment.
4 Verify
Used for Full Positive File, which is a full enrollment
transaction to verify that the sponsor's and payer's
systems are synchronized.
X BGN09 786 Security Level Code O ID 2/2
Code indicating the level of confidentiality assigned by the sender to the
information following
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 7
Segment: REF Transaction Set Policy Number
Position: 030
Loop:
Level: Heading:
Usage: Optional
Max Use: 1
Purpose: To specify identifying information
Syntax Notes: 1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
3 If either C04005 or C04006 is present, then the other is required.
Semantic Notes: 1 REF04 contains data relating to the value cited in REF02.
Comments:
Notes: Example: REF~38~001.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> REF01 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
38 Master Policy Number
Value of '38' is used for Reporting Carrier ID - the
carrier that administers coverage or distributes data to
other carriers
>> REF02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Contains Reporting Carrier ID
X REF03 352 Description X AN 1/80 A free-form description to clarify the related data elements and their content
X REF04 C040 Reference Identifier O
To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
X C04001 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04002 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04003 128 Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04004 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04005 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04006 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Ford Motor Company
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Segment: DTP File Effective Date
Position: 040
Loop:
Level: Heading:
Usage: Optional
Max Use: >1
Purpose: To specify any or all of a date, a time, or a time period
Syntax Notes:
Semantic Notes: 1 DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes: Example: DTP~007~D8~20010723.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> DTP01 374 Date/Time Qualifier M ID 3/3
Code specifying type of date or time, or both date and time
007 Effective
Value of '007' represents a report data or the date the
data was generated in the system.
>> DTP02 1250 Date Time Period Format Qualifier M ID 2/3 Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
>> DTP03 1251 Date Time Period M AN 1/35 Expression of a date, a time, or range of dates, times or dates and times
Used to communicate report date.
Ford Motor Company
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Segment: N1 Sponsor Name
Position: 070
Loop: 1000A Mandatory
Level: Heading:
Usage: Mandatory
Max Use: 1
Purpose: To identify a party by type of organization, name, and code
Syntax Notes: 1 At least one of N102 or N103 is required.
2 If either N103 or N104 is present, then the other is required.
Semantic Notes:
Comments: 1 This segment, used alone, provides the most efficient method of providing
organizational identification. To obtain this efficiency the "ID Code" (N104) must
provide a key to the table maintained by the transaction processing party.
2 N105 and N106 further define the type of entity in N101.
Notes: Example: N1~P5~NESC - HRIMS Daily Change~FI~380549190.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N101 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
P5 Plan Sponsor
Value of 'P5' used to indicate Systems Source Type.
N102 will contain employer and file type of daily, or
full positive.
N102 93 Name X AN 1/60 Free-form name
If daily change, N102 will contain "PEOPLESOFT DAILY CHANGE"
If Information Copy (BGN01=22), N102 will contain "PEOPLESOFT FULL
POS"
>> N103 66 Identification Code Qualifier M ID 1/2 Code designating the system/method of code structure used for Identification
Code (67)
FI Federal Taxpayer's Identification Number
The developers recommend that this code be used until
the HIPAA standard identifier is implemented.
ZZ Mutually Defined
The value 'ZZ', when used in this data element shall be
defined as "HIPAA Employer Identifier" once this
identifier has been adopted. Under the Health Insurance
Portability and Accountability Act of 1996, the
Secretary of the Department of Health and Human
Services must adopt a standard employer identifier for
use in this transaction.
>> N104 67 Identification Code M AN 2/80 Code identifying a party or other code
This will contain Ford's Federal Taxpayer ID Number until the HIPAA
Employer Identifier is adopted.
X N105 706 Entity Relationship Code O ID 2/2 Code describing entity relationship
Refer to 004010 Data Element Dictionary for acceptable code values.
X N106 98 Entity Identifier Code O ID 2/3
Code identifying an organizational entity, a physical location, property or an
individual
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
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Segment: N1 Payer
Position: 070
Loop: 1000B Mandatory
Level: Heading:
Usage: Mandatory
Max Use: 1
Purpose: To identify a party by type of organization, name, and code
Syntax Notes: 1 At least one of N102 or N103 is required.
2 If either N103 or N104 is present, then the other is required.
Semantic Notes:
Comments: 1 This segment, used alone, provides the most efficient method of providing
organizational identification. To obtain this efficiency the "ID Code" (N104) must
provide a key to the table maintained by the transaction processing party.
2 N105 and N106 further define the type of entity in N101.
Notes: Example: N1~IN~ABC Health Insurance~XV~555.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N101 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
IN Insurer
Value of 'IN' indicates that N102 will contain the
Reporting Carrier Name.
N102 93 Name X AN 1/60 Free-form name
Will contain Reporting Carrier Name.
>> N103 66 Identification Code Qualifier M ID 1/2 Code designating the system/method of code structure used for Identification
Code (67)
FI Federal Taxpayer's Identification Number
XV Health Care Financing Administration National Payer
Identification Number (PAYERID)
Required if the National PlanID is mandated for use.
Otherwise, one of the other listed codes may be used.
This code will be used to indicate a Carrier ID in N104
until the National PlanID is mandated for use.
>> N104 67 Identification Code M AN 2/80 Code identifying a party or other code
This field will contain the Reporting Carrier ID
X N105 706 Entity Relationship Code O ID 2/2
Code describing entity relationship
Refer to 004010 Data Element Dictionary for acceptable code values.
X N106 98 Entity Identifier Code O ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 11
Segment: INS Member Level Detail
Position: 010
Loop: 2000 Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To provide benefit information on insured entities
Syntax Notes: 1 If either INS11 or INS12 is present, then the other is required.
Semantic Notes: 1 INS01 indicates status of the insured. A "Y" value indicates the insured is a
subscriber: an "N" value indicates the insured is a dependent.
2 INS10 is the handicapped status indicator. A "Y" value indicates an individual is
handicapped; an "N" value indicates an individual is not handicapped.
3 INS12 is the date of death.
4 INS14, INS15, and INS16 identify where the employee works.
5 INS17 is the number assigned to each family member born with the same birth date.
This number identifies birth sequence for multiple births allowing proper tracking
and response of benefits for each dependent (i.e., twins, triplets, etc.).
Comments:
Notes: Example: INS~Y~18~021~28~A~~~FT.
INS~N~01~021~028~A~~~FT~~~~~~~~~1.
INS~Y~01~021~11~A~~~RT.
INS~N~19~021~11~A~~~RT~~~~~~~~~2.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> INS01 1073 Yes/No Condition or Response Code M ID 1/1 Code indicating a Yes or No condition or response
N No
Value of 'N' represents a dependent.
Y Yes
Value of 'Y' represents the Primary Insured (Employee).
>> INS02 1069 Individual Relationship Code M ID 2/2 Code indicating the relationship between two individuals or entities
01 Spouse
15 Ward
By Trading Partner Agreement, Ford will use this value
to denote "court-ordered dependents". Carrier should
bill Ford as primary for court-ordered dependants.
17 Stepson or Stepdaughter
18 Self
19 Child
Dependent between the ages of 0 and 19; age
qualifications may vary depending on policy
23 Sponsored Dependent
Refer to the Ford Trading Partner Guide for a definition
of this type of dependent.
38 Collateral Dependent
A child who is related to the primary enrollee by blood
or marriage and is claimed as an exemption by the
primary enrollee for federal income tax purposes. The
child is eligible for company-provided coverage until
the end of the year they reach age 25 if they meet the
above criteria. Examples are grandchildren, nieces,
nephews, sisters, brothers.
53 Life Partner
>> INS03 875 Maintenance Type Code M ID 3/3 Code identifying the specific type of item maintenance
Ford Motor Company
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001 Change
This code is used to indicate a change to an existing
subscriber/dependent record.
021 Addition
This code is used to indicate an addition of a subscriber
or dependent.
030 Audit or Compare
This code is used in conjunction with N102 in 1000A
loop and BGN01 to represent an audit or compare for
verification that the sponsor and the payer databases are
synchronized. In this case, N102 in the 1000A loop
will contain "PEOPLESOFT FULL POS" and
BGN01=22
INS04 1203 Maintenance Reason Code O ID 2/3
Code identifying the reason for the maintenance change
25 Change in Identifying Data Elements
A change has been made to the primary elements that
identify a specific employee. Such elements are first
name, last name, social security number, date of birth,
and employee identification number
This code value is used to represent that there is a
change to the contract.
28 Initial Enrollment
11 Surviving Spouse
By Trading Partner Agreement, this code value is used
to denote Spouse Only or Spouse and Dependent Only
XN Notification Only
>> INS05 1216 Benefit Status Code M ID 1/1 The type of coverage under which benefits are paid
A Active
S Surviving Insured
INS06 1218 Medicare Plan Code O ID 1/1 Code identifying the Medicare Plan
A Medicare Part A
Portion of Medicare bill involving patient's hospital
stay; hospital insurance
B Medicare Part B
Portion of Medicare bill involving charges by doctor, or
other non hospital related services
C Medicare Part A and B
X INS07 1219 Consolidated Omnibus Budget Reconciliation Act
(COBRA) Qualifying Event Code
O ID 1/2
A Qualifying Event is any of the following which results in loss of coverage
for a Qualified Beneficiary
Refer to 004010 Data Element Dictionary for acceptable code values.
INS08 584 Employment Status Code O ID 2/2
Code showing the general employment status of an employee/claimant
FT Full-time
Value of FT used as default for all non-retired
subscribers.
RT Retired
X INS09 1220 Student Status Code O ID 1/1 Code indicating the student status of the patient if 19 years of age or older, not
handicapped and not the insured
Refer to 004010 Data Element Dictionary for acceptable code values.
INS10 1073 Yes/No Condition or Response Code O ID 1/1
Code indicating a Yes or No condition or response
Ford Motor Company
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Y Yes
Used to identify all totally and permanently disabled
dependents.
INS11 1250 Date Time Period Format Qualifier X ID 2/3
Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
Must be provided if date of death is reported in INS12.
Only used by NESC to report date of death.
INS12 1251 Date Time Period X AN 1/35
Expression of a date, a time, or range of dates, times or dates and times
Used to report date of death of the subscriber/dependent.
X INS13 1165 Confidentiality Code O ID 1/1
Code indicating the access to insured information
Refer to 004010 Data Element Dictionary for acceptable code values.
X INS14 19 City Name O AN 2/30
Free-form text for city name
X INS15 156 State or Province Code O ID 2/2
Code (Standard State/Province) as defined by appropriate government agency
X INS16 26 Country Code O ID 2/3 Code identifying the country
INS17 1470 Number O N0 1/9 A generic number
A number used to uniquely identify each dependent for a contract.
Ford Motor Company
fd834O (004010) July 21, 2006 14
Segment: REF Subscriber Number
Position: 020
Loop: 2000 Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To specify identifying information
Syntax Notes: 1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
3 If either C04005 or C04006 is present, then the other is required.
Semantic Notes: 1 REF04 contains data relating to the value cited in REF02.
Comments:
Notes: Examples: REF~0F~123456789.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> REF01 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
0F Subscriber Number
At least 1 '0F' is required to report employee's Social
Security Number (without hyphens).
>> REF02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Will contain employee's Social Security Number.
X REF03 352 Description X AN 1/80 A free-form description to clarify the related data elements and their content
X REF04 C040 Reference Identifier O
To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
X C04001 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04002 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04003 128 Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04004 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04005 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04006 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Ford Motor Company
fd834O (004010) July 21, 2006 15
Segment: REF Member Identification Number
Position: 020
Loop: 2000 Mandatory
Level: Summary:
Usage: Optional
Max Use: 6
Purpose: To specify identifying information
Syntax Notes: 1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
3 If either C04005 or C04006 is present, then the other is required.
Semantic Notes: 1 REF04 contains data relating to the value cited in REF02.
Comments:
Notes: Examples: REF~F6~234567890D.
REF~ZZ~123.
REF~17~A.
REF~DX.001.
REF~Q4~555666777.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> REF01 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
17 Client Reporting Category
Code assigned by the client to categorize participants
for reporting requirements
Used to identify Union Code.
DX Department/Agency Number
Used to identify Ford company code.
F6 Health Insurance Claim (HIC) Number
A unique number assigned by the government to each
person entitled to Medicare benefits
Used to identify the Medicare Number.
Q4 Prior Identifier Number
Used to identify the contract/social security number of a
policy in which this individual was previously covered.
ZZ Mutually Defined
Used to identify the carrier that is providing the basic
HSM coverage.
>> REF02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X REF03 352 Description X AN 1/80 A free-form description to clarify the related data elements and their content
X REF04 C040 Reference Identifier O
To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
X C04001 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04002 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04003 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04004 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
Ford Motor Company
fd834O (004010) July 21, 2006 16
specified by the Reference Identification Qualifier
X C04005 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04006 127 Reference Identification X AN 1/30
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Ford Motor Company
fd834O (004010) July 21, 2006 17
Segment: DTP Member Level Dates
Position: 025
Loop: 2000 Mandatory
Level: Summary:
Usage: Optional
Max Use: 20
Purpose: To specify any or all of a date, a time, or a time period
Syntax Notes:
Semantic Notes: 1 DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes:
Example: DTP~336~D8~20010801.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> DTP01 374 Date/Time Qualifier M ID 3/3
Code specifying type of date or time, or both date and time
286 Retirement date
Date on which the subscriber or dependent retired
336 Employment Begin
This qualifier will be used to communicate the Ford
Service Date
>> DTP02 1250 Date Time Period Format Qualifier M ID 2/3 Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
>> DTP03 1251 Date Time Period M AN 1/35 Expression of a date, a time, or range of dates, times or dates and times
Will contain Retirement Date or Ford Service Date
Ford Motor Company
fd834O (004010) July 21, 2006 18
Segment: NM1 Member Name
Position: 030
Loop: 2100A Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.
2 If NM111 is present, then NM110 is required.
Semantic Notes: 1 NM102 qualifies NM103.
Comments: 1 NM110 and NM111 further define the type of entity in NM101.
Notes: Example: NM1~IL~1~DOE~JOHN~J~~~34~345678901.
NM1~74~1~DOE~JOHN~J~~~74~345678901.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> NM101 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
74 Corrected Insured
This code is used to correct identifier information on a
member already enrolled. When this code is used,
another NM1 segment is sent with a code of '70' in loop
2100B.
IL Insured or Subscriber
>> NM102 1065 Entity Type Qualifier M ID 1/1 Code qualifying the type of entity
1 Person
>> NM103 1035 Name Last or Organization Name M AN 1/35 Individual last name or organizational name
This field will contain the last name of the subscriber.
>> NM104 1036 Name First M AN 1/25 Individual first name
This field will contain the first name of the subscriber.
NM105 1037 Name Middle O AN 1/25 Individual middle name or initial
This field will contain the middle name of the subscriber.
NM106 1038 Name Prefix O AN 1/10 Prefix to individual name
NM107 1039 Name Suffix O AN 1/10 Suffix to individual name
NM108 66 Identification Code Qualifier X ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
34 Social Security Number
ZZ Mutually Defined
Value is required if National Individual Identifier is
mandated for use. Otherwise, one of the other listed
codes may be used. Since National Individual ID is not
yet mandated for use, Ford Motor Company will use a
qualifier of 34 with a Social Security Number in
NM109.
NM109 67 Identification Code X AN 2/80
Code identifying a party or other code
Will contain Social Security Number of subscriber (9 digits with no hyphens).
Ford Motor Company
fd834O (004010) July 21, 2006 19
X NM110 706 Entity Relationship Code X ID 2/2 Code describing entity relationship
Refer to 004010 Data Element Dictionary for acceptable code values.
X NM111 98 Entity Identifier Code O ID 2/3
Code identifying an organizational entity, a physical location, property or an
individual
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 20
Segment: PER Member Communications Numbers
Position: 040
Loop: 2100A Mandatory
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To identify a person or office to whom administrative communications should be directed
Syntax Notes: 1 If either PER03 or PER04 is present, then the other is required.
2 If either PER05 or PER06 is present, then the other is required.
3 If either PER07 or PER08 is present, then the other is required.
Semantic Notes:
Comments:
Notes: Example: PER~IP~~TE~5552125555.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> PER01 366 Contact Function Code M ID 2/2 Code identifying the major duty or responsibility of the person or group named
IP Insured Party
X PER02 93 Name O AN 1/60 Free-form name
>> PER03 365 Communication Number Qualifier M ID 2/2 Code identifying the type of communication number
TE Telephone
>> PER04 364 Communication Number M AN 1/80 Complete communications number including country or area code when
applicable
Will contain the telephone number of the subscriber.
X PER05 365 Communication Number Qualifier X ID 2/2 Code identifying the type of communication number
Refer to 004010 Data Element Dictionary for acceptable code values.
X PER06 364 Communication Number X AN 1/80 Complete communications number including country or area code when
applicable
X PER07 365 Communication Number Qualifier X ID 2/2 Code identifying the type of communication number
Refer to 004010 Data Element Dictionary for acceptable code values.
X PER08 364 Communication Number X AN 1/80
Complete communications number including country or area code when
applicable
X PER09 443 Contact Inquiry Reference O AN 1/20 Additional reference number or description to clarify a contact number
Ford Motor Company
fd834O (004010) July 21, 2006 21
Segment: N3 Member Residence Street Address
Position: 050
Loop: 2100A Mandatory
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To specify the location of the named party
Syntax Notes:
Semantic Notes:
Comments:
Notes: Mandatory for employee add or when submitting a change of address for the employee.
Example: N3~255 Main Street.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N301 166 Address Information M AN 1/55
Address information
N302 166 Address Information O AN 1/55 Address information
Required if a second address line exists.
Ford Motor Company
fd834O (004010) July 21, 2006 22
Segment: N4 Member Residence City, State, Zip Code
Position: 060
Loop: 2100A Mandatory
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax Notes: 1 If N406 is present, then N405 is required.
Semantic Notes:
Comments: 1 A combination of either N401 through N404, or N405 and N406 may be adequate to
specify a location.
2 N402 is required only if city name (N401) is in the U.S. or Canada.
Notes: Mandatory for employee add or when submitting a change of address for the employee.
Example: N4~Dearborn~MI~48126.
N4~Dearborn~MI~48126~60~US (for International Service Employees only)
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N401 19 City Name M AN 2/30 Free-form text for city name
N402 156 State or Province Code O ID 2/2 Code (Standard State/Province) as defined by appropriate government agency
This field is mandatory for addresses in the US and Canada (CA).
N403 116 Postal Code O ID 3/15 Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
This field is mandatory for addresses in the US and Canada (CA).
N404 26 Country Code X ID 2/3 Code identifying the country
N405 309 Location Qualifier X ID 1/2 Code identifying type of location
60 Area
Defined by trading partner agreement to indicate host country/work
location (used only for International Service Employees)
N406 310 Location Identifier O AN 1/30 Code which identifies a specific location
Defined by trading partner agreement to contain the host country for
International Service Employees
Ford Motor Company
fd834O (004010) July 21, 2006 23
Segment: DMG Member Demographics
Position: 080
Loop: 2100A Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To supply demographic information
Syntax Notes: 1 If either DMG01 or DMG02 is present, then the other is required.
Semantic Notes: 1 DMG02 is the date of birth.
2 DMG07 is the country of citizenship.
3 DMG09 is the age in years.
Comments:
Notes: Example: DMG~D8~19670630~M.
DMG~D8~19530101~F~~~~CN
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> DMG01 1250 Date Time Period Format Qualifier M ID 2/3 Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
>> DMG02 1251 Date Time Period M AN 1/35 Expression of a date, a time, or range of dates, times or dates and times
Used to communicate date of birth.
>> DMG03 1068 Gender Code M ID 1/1 Code indicating the sex of the individual
F Female
M Male
U Unknown
X DMG04 1067 Marital Status Code O ID 1/1 Code defining the marital status of a person
Refer to 004010 Data Element Dictionary for acceptable code values.
X DMG05 1109 Race or Ethnicity Code O ID 1/1 Code indicating the racial or ethnic background of a person; it is normally self-
reported; Under certain circumstances this information is collected for United
States Government statistical purposes
Refer to 004010 Data Element Dictionary for acceptable code values.
DMG06 1066 Citizenship Status Code O ID 1/2
Code indicating citizenship status
Refer to 004010 Data Element Dictionary for acceptable code values.
DMG07 26 Country Code O ID 2/3
Code identifying the country
This element is used to denote home country/citizenship by trading partner
agreement. Used only for International Service Employees.
X DMG08 659 Basis of Verification Code O ID 1/2 Code indicating the basis of verification
Refer to 004010 Data Element Dictionary for acceptable code values.
X DMG09 380 Quantity O R 1/15
Numeric value of quantity
Ford Motor Company
fd834O (004010) July 21, 2006 24
Segment: ICM Member Income
Position: 110
Loop: 2100A Mandatory
Level: Detail
Usage: Optional
Max Use: 1
Purpose: To supply information to determine benefit eligibility, deductibles, and retirement and
investment contributions
Syntax Notes:
Semantic Notes: 1 ICM01 is the frequency at which an individual's wages are paid.
2 ICM02 is the yearly wages amount.
3 ICM03 is the weekly hours.
4 ICM04 is the employer location qualifier such as a department number.
Comments:
Notes: Example: ICM~U~0~~1028~HRLY.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> ICM01 594 Frequency Code M ID 1/1 Code indicating frequency or type of payment
U Unknown
This is used as a default value.
>> ICM02 782 Monetary Amount M R 1/18 Monetary amount
0 is the default amount.
X ICM03 380 Quantity O R 1/15 Numeric value of quantity
>> ICM04 310 Location Identifier M AN 1/30 Code which identifies a specific location
This field is used to identify plant number/employee location.
>> ICM05 1214 Salary Grade M AN 1/5 The salary grade code assigned by the employer
Value of ICM05 will be "HRLY" to denote hourly, "SLRY" to denote salary,
"HD" for Hourly Deceased, or "SD" for Salary Deceased.
X ICM06 100 Currency Code O ID 3/3 Code (Standard ISO) for country in whose currency the charges are specified
Ford Motor Company
fd834O (004010) July 21, 2006 25
Segment: AMT Member Policy Amounts
Position: 120
Loop: 2100A Optional
Level: Detail
Usage: Optional
Max Use: 1
Purpose: To indicate total monetary amount
Syntax Notes:
Semantic Notes:
Comments: This segment will be used to identify those hourly employees who retire prior to1/1/04
for the purposes of placing the retirees in the appropriate drug co-payment groups as
specified in the Ford Purchasing letter on this subject.
The segment will also be used to identify those employees who are enrolled in a High
Deductible Health Plan.
Notes: Example: AMT~C1~0.
AMT~B9~1.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> AMT01 522 Frequency Code M ID 1/3 Code indicating frequency or type of payment
B9 Co-Insurance – Actual
This qualifier is used when AMT02 is '1' for those
salaried employees who are enrolled in a High
Deductible Health Plan (HDHP)
C1 Co-Payment Amount
This qualifier is used when AMT02 is '0' for those
hourly retirees with a retirement date prior to 1/1/04 and
who qualify for a reduced drug co-payment plan.
>> AMT02 782 Monetary Amount M R 1/18 Monetary amount
'0' is used as an indicator that the member is an hourly employee who has
retired prior to 1/1/04 and who qualifies for a reduced drug co-payment .
'1' is used to indicate that the member is enrolled in the HDHP.
Neither 0 nor 1 are intended to represent actual amounts. They are to be used
only as indicators of the above.
Ford Motor Company
fd834O (004010) July 21, 2006 26
Segment: NM1 Incorrect Member Name
Position: 030
Loop: 2100B Optional
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
This segment will be used to correct a Social Security Number that was previously
reported incorrectly.
Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.
2 If NM111 is present, then NM110 is required.
Semantic Notes: 1 NM102 qualifies NM103.
Comments: 1 NM110 and NM111 further define the type of entity in NM101.
Notes: Example: NM1~70~1~DOE~JOHN~J~~~34~111222333.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> NM101 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
70 Prior Incorrect Insured
This code value is used when correcting a SSN for a
member already enrolled. In this case, NM109 will
contain the incorrect SSN that was previously sent in
error.
>> NM102 1065 Entity Type Qualifier M ID 1/1 Code qualifying the type of entity
1 Person
>> NM103 1035 Name Last or Organization Name M AN 1/35 Individual last name or organizational name
This field will contain the last name of the subscriber.
>> NM104 1036 Name First M AN 1/25 Individual first name
This field will contain the first name of the subscriber.
NM105 1037 Name Middle O AN 1/25 Individual middle name or initial
This field will contain the middle name of the subscriber.
NM106 1038 Name Prefix O AN 1/10 Prefix to individual name
NM107 1039 Name Suffix O AN 1/10 Suffix to individual name
NM108 66 Identification Code Qualifier X ID 1/2
Code designating the system/method of code structure used for Identification
Code (67)
34 Social Security Number
ZZ Mutually Defined
Value is required if National Individual Identifier is
mandated for use. Otherwise, one of the other listed
codes may be used. Since National Individual ID is not
yet mandated for use, Ford Motor Company will use a
qualifier of 34 with a Social Security Number in
NM109.
NM109 67 Identification Code X AN 2/80
Code identifying a party or other code
Will contain Social Security Number of subscriber (9 digits with no hyphens).
Ford Motor Company
fd834O (004010) July 21, 2006 27
X NM110 706 Entity Relationship Code X ID 2/2 Code describing entity relationship
Refer to 004010 Data Element Dictionary for acceptable code values.
X NM111 98 Entity Identifier Code O ID 2/3
Code identifying an organizational entity, a physical location, property or an
individual
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 28
Segment: NM1 Custodial Parent
Position: 030
Loop: 2100F Optional
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Syntax Notes: 1 If either NM108 or NM109 is present, then the other is required.
2 If NM111 is present, then NM110 is required.
Semantic Notes: 1 NM102 qualifies NM103.
Comments: 1 NM110 and NM111 further define the type of entity in NM101.
Notes: This loop is used to transmit custodial parent information for a QMCSO (Qualified
Medical Court Support Order) dependent. Ford determines QMCSO eligibility status
based on "Procedures for Detraction and Administration of Qualified Medical Court
Support Order under ERISA". QMCSO eligibility entitles the custodial parent to obtain
and receive information pertaining to the QMCSO specified dependent. The carrier is
required to accept and store the custodial parent name and address, in accordance with
Ford business requirements.
Example: NM1~S3~1~DOE~JANE~K.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> NM101 98 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
S3 Custodial Parent
>> NM102 1065 Entity Type Qualifier M ID 1/1 Code qualifying the type of entity
1 Person
>> NM103 1035 Name Last or Organization Name M AN 1/35 Individual last name or organizational name
Will contain last name of custodial parent.
>> NM104 1036 Name First M AN 1/25 Individual first name
Will contain first name of custodial parent.
NM105 1037 Name Middle O AN 1/25 Individual middle name or initial
Will contain middle name of custodial parent.
NM106 1038 Name Prefix O AN 1/10 Prefix to individual name
NM107 1039 Name Suffix O AN 1/10 Suffix to individual name
X NM108 66 Identification Code Qualifier X ID 1/2 Code designating the system/method of code structure used for Identification
Code (67)
34 Social Security Number
X NM109 67 Identification Code X AN 2/80
Code identifying a party or other code
X NM110 706 Entity Relationship Code X ID 2/2
Code describing entity relationship
Refer to 004010 Data Element Dictionary for acceptable code values.
X NM111 98 Entity Identifier Code O ID 2/3 Code identifying an organizational entity, a physical location, property or an
individual
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 29
Segment: N3 Custodial Parent Street Address
Position: 050
Loop: 2100F Optional
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To specify the location of the named party
Syntax Notes:
Semantic Notes:
Comments:
Notes: Required for a QMCSO dependent with a custodial parent residing at a different address.
Example: N3~255 Main Street.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N301 166 Address Information M AN 1/55 Address information
N302 166 Address Information O AN 1/55 Address information
Required if a second address line exists.
Ford Motor Company
fd834O (004010) July 21, 2006 30
Segment: N4 Custodial Parent City, State, Zip
Position: 060
Loop: 2100F Optional
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax Notes: 1 If N406 is present, then N405 is required.
Semantic Notes:
Comments: 1 A combination of either N401 through N404, or N405 and N406 may be adequate to
specify a location.
2 N402 is required only if city name (N401) is in the U.S. or Canada.
Notes: Required for a QMCSO dependent with a custodial parent residing at a different address.
Example: N4~Dearborn~MI~48126.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> N401 19 City Name M AN 2/30 Free-form text for city name
N402 156 State or Province Code O ID 2/2 Code (Standard State/Province) as defined by appropriate government agency
This field is mandatory for addresses in the US and Canada (CA).
N403 116 Postal Code O ID 3/15 Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
This field is mandatory for addresses in the US and Canada (CA).
N404 26 Country Code X ID 2/3 Code identifying the country
X N405 309 Location Qualifier X ID 1/2 Code identifying type of location
Refer to 004010 Data Element Dictionary for acceptable code values.
X N406 310 Location Identifier O AN 1/30 Code which identifies a specific location
Ford Motor Company
fd834O (004010) July 21, 2006 31
Segment: HD Health Coverage
Position: 260
Loop: 2300 Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To provide information on health coverage
Syntax Notes:
Semantic Notes: 1 HD06 is the number of collateral dependents for the primary insured. A collateral
dependent is a relative related by blood or marriage who resides in the home and is
dependent on the employee for support.
2 HD07 is the number of sponsored dependents for the primary insured. A sponsored
dependent is a dependent between the ages of 19 and 25 who is not in school.
3 HD09 is a late enrollee indicator. A "Y" value indicates the insured is a late enrollee,
which can result in a reduction of benefits; an "N" value indicates the insured is a
regular enrollee.
4 HD11 is a prescription drug service coverage indicator. A "Y" value indicates that
prescription drug service coverage applies; an "N" value indicates that prescription
drug service coverage does not apply.
Comments:
Notes: Examples: HD~021~~HLT~FMP~ESP.
HD~021~~HLT~LAB~ESP.
HD~021~~DEN~~FAM.
HD~021~~LTD~A.
HD~021~~HLT~~SPC.
HD~021~~HLT~~SPO.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> HD01 875 Maintenance Type Code M ID 3/3 Code identifying the specific type of item maintenance
001 Change
Used to report a change in coverage information.
021 Addition
Used to add coverage.
024 Cancellation or Termination
Used to cancel coverage.
030 Audit or Compare
X HD02 1203 Maintenance Reason Code O ID 2/3 Code identifying the reason for the maintenance change
Refer to 004010 Data Element Dictionary for acceptable code values.
>> HD03 1205 Insurance Line Code M ID 2/3
Code identifying a group of insurance products
AG Preventive Care/Wellness
DEN Dental
HE Hearing
HLT Health
LTD Long-Term Disability
A plan that provides a source of monthly income for
covered employees who are unable to work because of
total disability; benefits are payable for a period of 5 to
10 years, or more commonly to the employee's normal
age of retirement
This value will be used to represent life insurance
coverage. Agreement was made with the carrier to use
this value since there is no value available for this
purpose.
Ford Motor Company
fd834O (004010) July 21, 2006 32
PDG Prescription Drug
STD Short-Term Disability
A plan that provides a source of income for covered
employees who are unable to work because of
disability; benefits are payable for a period of 13, 26, or
52 weeks
VIS Vision
HD04 1204 Plan Coverage Description O AN 1/50
A description or number that identifies the plan or coverage
Used to communicate insurance coverage level code (Ford Medical Plan,
Comprehensive Medical Plan or Basic Medical Plan). Value will be "FMP",
"CMP or "BMP". Also used to communicate Lab (HD04=LAB), DME
(HD04=DME), Footcare (HD04=FOOTCARE) coverage, Physical Therapy
(HD04=PHYSICAL THERAPY), Imaging (HD04=IMAGING), with
HD03=HLT. Also used to communicate Life and Disability codes when
HD03=LTD or STD. Codes understood by trading partner agreement.
HD05 1207 Coverage Level Code O ID 3/3
Code indicating the level of coverage being provided for this insured
ECH Employee and Children
ESP Employee and Spouse
FAM Family
IND Individual
SPC Spouse and Children
SPO Spouse Only
TWO Two Party
X HD06 609 Count O N0 1/9 Occurrence counter
X HD07 609 Count O N0 1/9 Occurrence counter
X HD08 1209 Underwriting Decision Code O ID 1/1 Code indicating the decision made by the underwriter
Refer to 004010 Data Element Dictionary for acceptable code values.
X HD09 1073 Yes/No Condition or Response Code O ID 1/1 Code indicating a Yes or No condition or response
Refer to 004010 Data Element Dictionary for acceptable code values.
X HD10 1211 Drug House Code O ID 2/3 Code indicating a drug house with which the insurance plan is affiliated
Refer to 004010 Data Element Dictionary for acceptable code values.
X HD11 1073 Yes/No Condition or Response Code O ID 1/1 Code indicating a Yes or No condition or response
Refer to 004010 Data Element Dictionary for acceptable code values.
Ford Motor Company
fd834O (004010) July 21, 2006 33
Segment: DTP Health Coverage Dates
Position: 270
Loop: 2300 Mandatory
Level: Summary:
Usage: Mandatory
Max Use: 4
Purpose: To specify any or all of a date, a time, or a time period
Syntax Notes:
Semantic Notes: 1 DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes: Example: DTP~348~D8~20010801.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> DTP01 374 Date/Time Qualifier M ID 3/3
Code specifying type of date or time, or both date and time
303 Maintenance Effective
Date on which the maintenance is effective
(note: When a full positive file is sent, you could
potentially receive maintenance effective dates of all
zeros due to this data being unavailable at the time that
Ford populated its database).
348 Benefit Begin
Date on which the subscriber's or dependent's benefit
begin
349 Benefit End
Date on which the subscriber's or dependent's benefit
ends
>> DTP02 1250 Date Time Period Format Qualifier M ID 2/3 Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
>> DTP03 1251 Date Time Period M AN 1/35 Expression of a date, a time, or range of dates, times or dates and times
Ford Motor Company
fd834O (004010) July 21, 2006 34
Segment: REF Health Coverage Policy Number
Position: 290
Loop: 2300 Mandatory
Level: Summary:
Usage: Optional
Max Use: 3
Purpose: To specify identifying information
Syntax Notes: 1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
3 If either C04005 or C04006 is present, then the other is required.
Semantic Notes: 1 REF04 contains data relating to the value cited in REF02.
Comments:
Notes: Examples: REF~1L~555.
REF~ZZ~N.
REF~17~HAM.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> REF01 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
17 Client Reporting Category
Used to report the eVerest Segment Population Code
1L Group or Policy Number
Used to report Carrier ID.
ZZ Mutually Defined
Used to indicate termination action code for life
insurance, disability and vision coverage.
>> REF02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
REF02 will contain the eVerest Segment Population Code when REF01=17
REF02 will contain the Carrier ID when REF01=1L
REF02 will contain the termination action code for life insurance, disability or
vision coverage when REF01=ZZ
X REF03 352 Description X AN 1/80 A free-form description to clarify the related data elements and their content
X REF04 C040 Reference Identifier O
To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
X C04001 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04002 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04003 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04004 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04005 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04006 127 Reference Identification X AN 1/30
Ford Motor Company
fd834O (004010) July 21, 2006 35
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
Ford Motor Company
fd834O (004010) July 21, 2006 36
Segment: COB Coordination of Benefits
Position: 400
Loop: 2320 Optional
Level: Summary:
Usage: Optional
Max Use: 1
Purpose: To supply information on coordination of benefits
Syntax Notes:
Semantic Notes: 1 COB02 is the policy number.
Comments:
Notes: This loop is used to communicate Medicare A and B begin and end dates. A new COB
loop will be generated for each date transmitted. The loop is also used to communicate
the date that Medicare became primary or the date it became secondary. A new COB
loop is generated to communicate these dates.
Example: COB~P~~1.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> COB01 1138 Payer Responsibility Sequence Number Code M ID 1/1 Code identifying the insurance carrier's level of responsibility for a payment of
a claim
P Primary
S Secondary
X COB02 127 Reference Identification O AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
>> COB03 1143 Coordination of Benefits Code M ID 1/1 Code identifying whether there is a coordination of benefits
1 Coordination of Benefits
A method of integrating benefits payable under more
than one group health insurance plan so that the
insured's benefits from all sources do not exceed 100
percent of the allowable medical expenses
Value of "1" is used as a default value.
Ford Motor Company
fd834O (004010) July 21, 2006 37
Segment: REF Additional Coordination of Benefits Identifiers
Position: 405
Loop: 2320 Optional
Level: Summary:
Usage: Optional
Max Use: 5
Purpose: To specify identifying information
Syntax Notes: 1 At least one of REF02 or REF03 is required.
2 If either C04003 or C04004 is present, then the other is required.
3 If either C04005 or C04006 is present, then the other is required.
Semantic Notes: 1 REF04 contains data relating to the value cited in REF02.
Comments:
Notes: Used to report Medicare Part A and Medicare Part B and whether Medicare is primary or
secondary.
Examples: REF~ZZ~MEDA.
REF~ZZ~MEDB.
REF~ZZ~MEDPRIMARY.
REF~ZZ~MEDSECONDARY.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> REF01 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
ZZ Mutually Defined
>> REF02 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
For Medicare Part A, field will contain 'MEDA'
For Medicare Part B, field will contain 'MEDB'
If Medicare is primary, field will contain 'MEDPRIMARY'
If Medicare is secondary, field will contain 'MEDSECONDARY'
X REF03 352 Description X AN 1/80 A free-form description to clarify the related data elements and their content
X REF04 C040 Reference Identifier O
To identify one or more reference numbers or identification numbers as
specified by the Reference Qualifier
X C04001 128 Reference Identification Qualifier M ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04002 127 Reference Identification M AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04003 128 Reference Identification Qualifier X ID 2/3
Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04004 127 Reference Identification X AN 1/30 Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
X C04005 128 Reference Identification Qualifier X ID 2/3 Code qualifying the Reference Identification
Refer to 004010 Data Element Dictionary for acceptable code values.
X C04006 127 Reference Identification X AN 1/30
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
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Segment: DTP Coordination of Benefits Eligibility Dates
Position: 450
Loop: 2320 Optional
Level: Summary:
Usage: Optional
Max Use: 2
Purpose: To specify any or all of a date, a time, or a time period
Syntax Notes:
Semantic Notes: 1 DTP02 is the date or time or period format that will appear in DTP03.
Comments:
Notes: Example: DTP~344~D8~20011101.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> DTP01 374 Date/Time Qualifier M ID 3/3
Code specifying type of date or time, or both date and time
344 Coordination of Benefits Begin
Date on which Coordination of Benefits begin
Ford uses this qualifier to indicate Medicare A and B
Begin Dates and the date that Medicare became
primary.
345 Coordination of Benefits End
Date on which Coordination of Benefits end
Ford uses this qualifier to indicate Medicare A and B
End Dates and the date that Medicare became
secondary.
>> DTP02 1250 Date Time Period Format Qualifier M ID 2/3 Code indicating the date format, time format, or date and time format
D8 Date Expressed in Format CCYYMMDD
>> DTP03 1251 Date Time Period M AN 1/35 Expression of a date, a time, or range of dates, times or dates and times
Field will contain Medicare Begin or End Dates or the date that Medicare
became Primary or Secondary.
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Segment: SE Transaction Set Trailer
Position: 690
Loop:
Level: Summary:
Usage: Mandatory
Max Use: 1
Purpose: To indicate the end of the transaction set and provide the count of the transmitted
segments (including the beginning (ST) and ending (SE) segments)
Syntax Notes:
Semantic Notes:
Comments: 1 SE is the last segment of each transaction set.
Notes: Example: SE~40~0001.
Data Element Summary
Ref. Data
Des. Element Name Attributes
>> SE01 96 Number of Included Segments M N0 1/10
Total number of segments included in a transaction set including ST and SE
segments
>> SE02 329 Transaction Set Control Number M AN 4/9 Identifying control number that must be unique within the transaction set
functional group assigned by the originator for a transaction set
The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. For example, start with
the number 001 and increment from there. This number must be unique within
a specific group and interchange, but the number can repeat in other groups and
interchanges.
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Change Notes:
Change
Date
Loop Segment Element Change Description
1/22/2003 Updated guideline for posting on
GSEC web site. Changed delimiters
in examples and file name to match
Ford Standard.
4/17/2003 2100F Added comments in the 2100F loop
to indicate the purpose of the loop
and the requirement of the carrier to
store this data.
4/17/2003 2300 REF REF01 Removed qualifier of '17' from the
REF01 and the reference to APA in
REF02 as well as in the data example
in the notes section of the this
segment. The APA is no longer sent.
4/24/2003 Heading BGN BGN01 Removed value of '15' for
'resubmission' since Ford does not
use this value.
4/29/2003 2300 REF REF02 The termination action code is now
sent for vision coverage. Previously
sent for life and disability only.
9/3/03 2320 COB,
REF and
DTP
COB01,
REF02,
DTP01,
DTP03 of
the 2320
loop
Fields modified to accommodate
Medicare Primacy indicator/date and
Medicare Secondary indicator/date.
10/27/03 2100A AMT AMT01,
AMT02
New segment added to identify
Hourly Retirees who retired prior to
1/1/04.
11/20/03 2300 HD HD04 New notes added to indicate that Ford
will begin sending "PHYSICAL
THERAPY" and "IMAGING" in this
field.
11/20/03 2300 REF REF01 Added new value of '17' to transmit
the Everest Population Group. Also
added a data example and notes to
REF02 that this field will contain the
eVerest Population Group when
REF01=17
11/20/03 2100A ICM ICM05 Updated comments for ICM05 to
indicate new values of "HD" for
Hourly Deceased and "SD" for Salary
Deceased.
11/20/03 2300 HD HD04 Updated comments to indicate that
HD04 will also be used to transmit
Ford Motor Company
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coverage codes for life and disability.
8/23/05 1000A N1 N102 Updated comments to indicate
naming convention of files changed
to "PEOPLESOFT FULL POS" and
"PEOPLESOFT DAILY CHANGE"
and removed all references to the
monthly activity file since it is no
longer sent with the launch of
PeopleSoft.
1/6/06 2310 LX, NM1 Removed these segments. They were
previously used to transmit Primary
Care Physician data but have not
been used in quite some time. Also
marked them as not used in the
segment overview section.
1/6/06 Heading BGN BGN08 Removed reference to HRIMS and
NESC, since data is now fed from
PeopleSoft
1/6/06 Heading DTP DTP01 Removed reference to NESC and
HRIMS as well as the information
regarding the timing of delivery for
the full positive, since it is no longer
relevant.
2/15/06 2300 HD HD03 Added value of 'AG' for preventive
care
2/23/06 2100A AMT AMT01,
AMT02
Added qualifier of 'B9' to AMT01
and value of '1' to AMT02 for those
enrolled in the HDHP. Changed
wording for this segment as it
previously indicated that 'C1' for
AMT01 and '0' for AMT02 would be
used as default values. Now, this
segment may be used to indicate pre
1/1/04 retirees who qualify for a
lower drug co-pay plan as well as for
those members enrolled in a HDHP.
7/21/06 2100A N4 N405
N406
Changed these elements from "not
used" to "used" to accommodate
sending a host country/work location
for International Service Employees
7/21/06 2100A DMG DMG07 Changed this element from "not
used" to "used" to accommodate
sending a home country/citizenship
for International Service Employees