A service of Maryland Health Benefit Exchange

834 Business RulesJuly 18, 2013

Agenda

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Effectuation

Version

Scheduling

834 Transmission Business Rules

834 Transaction Set

Loop 2000 – Member Level Detail

Loop 2300 – Health Coverage

Loop 2750 – Reporting Categories

Q&A

834 Effectuation

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All carriers must enroll individuals and employees

upon receipt of the 834

834 Version

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Version for 10/1

– 5010220A1 standard for enrollment (834)

– Batch file processing only, no real time enrollment

transactions

– Outbound standard for Individual, SHOP,

reconciliation, CMS reporting

– Inbound standard from Carriers and TPAs utilize

same version

Inbound, Outbound Scheduling

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834 files from the Maryland Health Connection will be

transmitted during the nightly batch process

– Midnight to 5:00 am (pending production volume)

Maryland Health Connection expects

acknowledgements to be delivered within a 24 hour

window

834 files from the Carrier and TPAs will be

processed starting at 9:00 am

Maryland Health Connection generates

acknowledgements within a 24 hour window

834 EDI Transmission Business Rules

Transaction Set

Transaction Set

– We create one ST-SE transaction per family.

– Each family member will be indicated with INS

loop.

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Loop ID 2000 – Member Level Detail

Identifying the Member in 834 Transmissions.

This unique identifier HIX ID, is communicated to

the Carrier in the 834 transactions within the 2000

Member Level Detail loop.

The subscriber will have his/her own HIX ID while

each additional member eligible for coverage will

also have his/her own HIX ID.

Once an individual is assigned a HIX ID, he/she

keeps this identifier for as long as he/she

conducts business with the Exchange.

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Loop ID 2000 – Member Level Detail

Table below describes the various enrollee identifiers and their associated qualifier.

In addition, the enrollee’s SSN, if available, is transmitted in the NM1 segment on the initial enrollment transactions.

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Member Identifier Ref ID Qualifier

Notes

Exchange Assigned ID 0F When transmitted in the Subscriber

Identifier REF

Issuer Assigned Subscriber ID ZZ When transmitted in the Member

Supplemental Identifier REF

Exchange Assigned Member ID 17 Transmitted in the Member

Supplemental Identifier REF

Insurer Assigned Member ID 23 Transmitted in the MemberSupplemental Identifier REF

Loop ID 2000 – Member Level Detail

Each family member will be indicated with INS

loop.

The Exchange will send explicit

enrollment/terminations/cancellation in the INS

segment for each member.

Maintenance code will be reported specifically for

each member at INS and reporting category loop.

– INS*Y*18*021*28*A~

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Loop ID 2100A – Member Name

Communication contacts will be sent in the

following order:

1st – Primary Phone (TE)

2nd – Secondary Phone (AP)

3rd – Preferred Communication Method (EM for

email or BN for text message), either an email

address or phone number for receiving text

messages.

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Loop ID 2100A – Member Name

Member Health Information

Health Related Code – Information about tobacco

use will be sent on every enrollment transaction.

The three valid responses a QHP Issuer may

receive are:

– “N” No Tobacco Use, if indicated with QHP

selection

– “T” Tobacco Use, if indicated with QHP

selection

– “U” Unknown Tobacco Use, if not “N” or “T”

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LOOP ID 2300 – Health Coverage

An Enrollment effective Date is send on enrollment update transactions.

(DTP*303)

An Enrollment Period start Date is only send on initial enrollment transactions.

(DTP*348)

An Enrollment Period End Date is sent when cancelling or terminating an enrollment period.

(DTP*349)

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LOOP ID 2300 – Health Coverage

Maryland Health Connection creates single transaction for individual enrolled in medical and dental plans.

Maryland Health Connection sends one 2000 loop with one 2300 loop for the Medical Coverage and another 2300 loop for the Dental Coverage if individual elected both medical and dental plan from same carrier.

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LOOP ID 2310 – Provider Information

Maryland Health Connection sends 2310 loop only if

Plans require PCP to be selected. If not, this loop will

not be send.

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Loop 2750 – Reporting Categories

All information associated with the insurance premium

will be reported under the 2700 Member Reporting

Categories loop of the subscriber.

Financial information reported in the 2750 Loops

(within the 2700 loop) include the premium

amount (PRE AMT TOTAL), the APTC amount

(APTC) and the member premium amounts (PRE

AMT 1).

Maryland Health Connection derives the total

premium amount by adding all individual member

premium amounts.

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Loop 2750 – Reporting Categories

N101 – 75 (Participant)

N102 – APTC AMT

REF02 – will send APTC AMT

DTP03 – Effective Date of APTC AMT

APTC

– Amount the QHP issuer can expect to receive

toward the total premium payment (APTC)

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Loop 2750 – Reporting Categories

N101 – 75 (Participant)

N102 – Carrier to Bill

REF02 – Carrier ID

DTP03 – Start date of coverage

If an individual elects to pay the Carrier, this

information is sent in this reporting category loop

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Loop 2750 – Reporting Categories

N101 – 75 (Participant)

N102 – Premium Medical Amount

REF02 – Premium rate for Medical Coverage

DTP03 – Effective date of coverage

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Loop 2750 – Reporting Categories

N101 – 75 (Participant)

N102 – Premium Dental Amount

REF02 – Premium rate for Dental Coverage

DTP03 – Effective date of coverage

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Loop 2750 – Reporting Categories

N101 – 75 (Participant)

N102 – ADDL MAINT REASON

REF02 – TERM/CANCEL

DTP03 – Last day of coverage

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QUESTIONS?

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