Chapter 15C. AE – Administration Electronic - Zendesk · Chapter 15C. AE – Administration Electronic OVERVIEW This appendix contains all the field information for the Segment

Chapter 15C. AE – Administration Electronic OVERVIEW

This appendix contains all the field information for the Segment Name, the Segment ID Code, the Loop Report, the Segment Report, the EDI Field ID, the EDI Field Name, the EDI Required field, the Data Type, the Min Max, the Element Value, the Trading Partner Specific Value, and any Additional Descriptions required for the EDI 834 Outbound file.

A separate document, titled Chapter 15. Appendix C-Worksheet, which is delivered in MS Word format is also a part of the Appendix. The worksheet should be used by you whenever you need to edit the last two fields of the 834 Outbound information for use by your vendors>

APPENDIX 15C. AE – CHECKLIST AND Checklist -

PAGE 15-2

CHECKLIST 1. Review the Checklist items in Chapters 15. AE-Admin Electronic Processing.

2. Use the 834 X12 5010 Implementation Guide available to you through the Internetin addition to Appendix B as your complete implementation documentation.

3. (See www.sbpa.com for a list of links to other informative HIPAA web sites.)

GBAS V7.90 Administration August, 2006

http://www.sbpa.com/

APPENDIX 15C. AE – CHECKLIST AND Things You Need to Know Before Beginning -

PAGE 15-3

THINGS YOU NEED TO KNOW BEFORE BEGINNING How Appendix C is Organized

(See Chapter 15. AE-Admin Electronic Processing, section TPFM, for a discussion of the Trading Partner file.)


APPENDIX 15C. AE – 834 COMPANION GUIDE


PAGE 15-5

834 COMPANION GUIDE

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID

EDI FIELD NAME EDI REQ

DATA TYPE

MIN MAX

ELEMENT VALUE TRADING PARTNER SPECIFIC VALUE

ADDITIONAL DESCRIPTION

Interchange Control Header

ISA 1 Req 1st envelope segment used to identify the sender and define terminators used throughout the entire exchange.

ISA01 Authorization Information Qualifier

Req ID 2/2 Identifies the type of information in ISA02. 00

ISA02 Authorization Information

Req AN 10/10

Additional Identification or Authorization information about the sender. Blank (10 spaces required)

ISA03 Security Information Qualifier

Req ID 2/2 Identifies the type of information in ISA04. 00

ISA04 Security Information

Req AN 10/10

Password Blank (10 spaces required)

ISA05 Interchange ID Qualifier

Req ID 2/2 Identifies the system/method of code structure used to identify the sender ID. ZZ

ISA06 Interchange Sender ID

Req AN 15/15

Sender ID Code Must be agreed on by the Trading Partners and must match the Sender ID in the GenTran Partner Profile.

? Usually the sender's Federal Tax ID.

ISA07 Interchange ID Qualifier

Req ID 2/2 Identifies the system/method of code structure used to identify the receiver ID. ZZ



PAGE 15-6

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



ISA08 Interchange Receiver ID

Req AN 15/15

Receiver ID Code Must be agreed on by the Trading Partners and must match the Application ID in the Sender's GenTran Partner Profile.

? Usually the receiver's Federal Tax ID.

ISA09 Interchange Date Req DT 6/6 Date of Interchange YYMMDD

ISA10 Interchange Time Req TM 4/4 Time of Interchange HHMM

ISA11 Interchange Control Standards Identifier

Req ID 1/1 Identifies the agency responsible for control standards in headers and trailers. U

ISA12 Interchange Control Version Number

Req ID 5/5 Identifies the version number of the control standards 00401

ISA13 Interchange Control Number

Req N0 9/9 Control number assigned by the sender. Must be identical to the Interchange Trailer (IEA02).

ISA14 Acknowledgement Requested

Req ID 1/1 0 - No acknowledgment requested. 1 - Interchange acknowledgment requested. (TA1)

? Will a 997 be returned to the sender?

ISA15 Usage Indicator Req ID 1/1 P - Production Data T - Test Data Must match the test indicator defined in the Sender's GenTran Partner Profile.

? Must be coordinated through testing and into production.



PAGE 15-7

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



ISA16 Component Element Separator

Req 1/1 Identifies the delimiter used to separate multiple component data elements within a composite data structure. We recommend the use of a colon for this element. :

Functional Group Header

GS 1 Req To indicate the beginning of a functional group and to provide control information.

GS01 Functional Identifier Code

Req ID 2/2 Identifies the 834 - Benefit Enrollment and Maintenance transaction. BE

GS02 Application Sender's Code

Req AN 2/15 Identifies the party sending the transmission.Must be agreed on by the Trading Partners.

? Usually the sender's Federal Tax ID.

GS03 Application Receiver's Code

Req AN 2/15 Identifies the party receiving the transmission.Must be agreed on by the Trading Partners.

? Usually the receiver's Federal Tax ID.

GS04 Date Req DT 8/8 Transmission creation date CCYYMMDD

GS05 Time Req TM 4/8 Transmission creation time HHMM or HHMMSS or HHMMSSD or HHMMSSDD

GS06 Group Control Number

Req N0 1/9 Assigned number originated and maintained by the sender. This number must be identical to GE02 in the Functional Group Trailer.

GS07 Responsible Agency Code

Req ID 1/2 Code used in conjunction with GS08 to identify the issuer of the standard. X



PAGE 15-8

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



GS08 Version/Release/ Industry ID Code

Req AN 1/12 Code to identify the version, release, subrelease, and industry identifier of the EDI standard being used. 005010X095A1

Transaction Set Header

ST 1 Req Innermost envelope used to identify the start of a transaction set and to assign a control number.

ST01 Transaction Set Identifier Code

Req ID 3/3 Code uniquely identifying a transaction set. 834

ST02 Transaction Set Control Number

Req AN 4/9 Identifying control number that must be unique within the transaction set functional group assigned by the sender. Must match the value received in the corresponding SE field (SE02).

Beginning Segment

BGN 1 Req Indicates the beginning of a transaction set and specifies transaction wide characteristics.

BGN01 Transaction Set Purpose Code

Req ID 2/2 A code identifying the purpose of the transaction set. 00 – Original

BGN02 Transaction Set Identifier Code

Req AN 1/30 The value of this element will usually be a number that increments by one each time a transaction is created. This number must be unique among all historical 834 transactions.

BGN03 Transaction Set Creation Date

Req DT 8/8 Date the transaction was created CCYYMMDD

BGN04 Transaction Set Creation Time

Req TM 4/8 Time the transaction was created HHMM or HHMMSS or HHMMSSD or HHMMSSDD



PAGE 15-9

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



BGN05 Time Zone Code Opt ID 2/2 Code identifying the time zone. 01 - ISO P01 02 - ISO P02 03 - ISO P03 04 - ISO P04 05 - ISO P05 06 - ISO P06 07 - ISO P07 08 - ISO P08 09 - ISO P09 10 - ISO P10 11 - ISO P11 12 - ISO P12 13 - ISO M12 14 - ISO M11 15 - ISO M10 16 - ISO M09 17 - ISO M08 18 - ISO M07 19 - ISO M06 20 - ISO M05 21 - ISO M04 22 - ISO M03 23 - ISO M02 24 - ISO M01 AD - Alaska Daylight Time AS - Alaska Standard Time AT - Alaska Time CD - Central Daylight Time CS - Central Standard Time CT - Central Time ED - Eastern Daylight Time ES - Eastern Standard Time

? What time zone is the sender in?



PAGE 15-10

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



ET - Eastern Time GM - Greenwich Mean Time HD - Hawaii-Aleutian Daylight Time HS - Hawaii-Aleutian Standard Time HT - Hawaii-Aleutian Time LT - Local Time MD - Mountain Daylight Time MS - Mountain Standard Time MT - Mountain Time ND - Newfoundland Daylight Time NS - Newfoundland Standard Time NT - Newfoundland Time PD - Pacific Daylight Time PS - Pacific Standard Time PT - Pacific Time TD - Atlantic Daylight Time TS - Atlantic Standard Time TT - Atlantic Time UT - Universal Time Coordinate



PAGE 15-11

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



BGN08 Action Code Req ID 1/2 A code identifying the type of action for the transaction set. 4

Transaction Set Policy Number

REF 1 Opt Can be used if one Group Number applies to the entire transaction. If used, it may be superceded for individual members through the use of the Member Policy Number segment.

REF01 Reference Identification Qualifier

Req ID 2/3 Code qualifying the reference identification. 38

REF02 Master Policy Number

Req AN 1/30 Sender's Group Number ? What value, if any, will be used?

File Effective Date

DTP >1 Opt To specify different types of effective dates that apply to the entire transaction.

DTP01 Date / Time Qualifier

Req ID 3/3 Code specifying type of date or time. 007 = Effective 303 = Maintenance Effective 382 = Enrollment 388 = Payment Commencement All dates will print the date that the outbound process was run. They are all available optionally and can be enabled when agreed upon by both trading partners.

DTP02 Date Time Period Format Qualifier

Req ID 2/2 Date Time format qualifier. D8



PAGE 15-12

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DTP03 Date Time Period Req AN 1/35 Date in CCYYMMDD format. ? Which date type(s), if any, will be sent?

Sponsor Name N1 1 1 Req Used to pass the identification of the plan sponsor (sender).

N101 Entity Identifier Code

Req ID 2/3 Code that identifies the entity type. P5

N102 Plan Sponsor Name

Opt AN 1/60 Optional name of sponsor. ? What value, if any, will be used?

N103 Identification Code Qualifier

Req ID 1/2 A code identifying the structure used in N104.FI = Federal Taxpayer ID Number ZZ = Mutually Defined

? What kind of ID will be sent?

N104 Sponsor Identifier Req AN 2/80 A code that identifies the sender. ? Usually the sender's Federal Tax ID.

Payer N1 1 1 Req Used to pass the identification of the payer (receiver).


Req ID 2/3 Code that identifies the entity type. IN

N102 Insurer Name Opt AN 1/60 Optional name of payer ? What value, if any, will be used?

N103 Identification Code Qualifier

Req ID 1/2 A code identifying the structure used in N104.FI = Federal Taxpayer ID Number XV=Health Care Financing Administration National PlanId




PAGE 15-13

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



N104 Insurer Identification Code

Req AN 2/80 A code that identifies the receiver or payer. ? Usually the receiver's Federal Tax ID.

Member Level Detail

INS >1 1 Req Used to describe member information. It will repeat once for each member's information and is the start of the member data collection processing loop. This segment may not occur more than 10,000 times in a single 834 transaction. Receipt of this segment indicates that the prior Loop completed and we are now processing a new Member.

INS01 Insured Indicator Req ID 1/1 Used to define if the following segments in this loop are for the subscriber or a dependent. Y - Subscriber N - Dependent



PAGE 15-14

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



INS02 Individual Relationship Code

Req ID 2/2 A code that describes the relationship to the subscriber. 01 - Spouse 03 - Father or Mother 04 - Grandfather or Grandmother 05 - Grandson or Granddaughter 06 - Uncle or Aunt 07 - Nephew or Niece 08 - Cousin 09 - Adopted Child 10 - Foster Child 11 - Son-in-law or Daughter-in-law 12 - Brother-in-law or Sister-in-law 13 - Mother-in-law or Father-in-law 14 - Brother or Sister 15 - Ward 17 - Stepson or Stepdaughter 18 - Self 19 - Child 23 - Sponsored Dependent 24 - Dependent of a Minor Dependent 25 - Ex-spouse 26 - Guardian 31 - Court appointed Guardian 32 - Mother 33 - Father 38 - Collateral Dependent 48 - StepFather 49 - StepMother 53 - Life Partner

? What value(s) will be used?



PAGE 15-15

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



INS03 Maintenance Type Code

Req ID 3/3 A code that indicates the type of maintenance to be performed on the member. 030 = Audit or Compare.

INS04 Maintenance Reason Code

Opt ID 2/3 A code that defines what event has caused the action to be needed. XN = Notification Only

? Will this be sent?

INS05 Benefit Status Code

Req ID 1/1 The type of coverage under which benefits are paid. A - Active C - COBRA S - Surviving Insured (Not Used) T - TEFRA (Not Used)

INS06 Medicare Plan Code

Not Used

ID 1/1 A code that defines the Medicare Plan. A - Part A B - Part B C - Parts A and B D - Part Unknown E - None

INS07 COBRA Qualifying

Opt ID 1/2 A qualifying event which results in the loss of coverage for a qualified beneficiary. 1 - Termination of Employment 2 - Reduction of work hours 3 - Medicare 4 - Death 5 - Divorce 6 - Separation 7 - Ineligible Child 8 - Bankruptcy of a Retired Employee

? Which values(s), if any will be used?



PAGE 15-16

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



INS08 Employment Status Code

Not Used

ID 2/2 Code showing the general employment status of an employee/claimant. AO - Active Military - Overseas AU - Active Military - USA FT - Full-Time L1 - Leave of Absence PT - Part-Time RT - Retired TE - Terminated

INS09 Student Status Code

Opt ID 1/1 A code to define the student status for this member. F - Full Time N - Not a Student

INS10 Handicap Indicator

Not Used

ID 1/1 A value indicating whether the member is handicapped or not. Y - Handicapped N - Not Handicapped

INS11 Date Time Period Format Qualifier

Not Used

ID 2/3 Date Time format. D8 Required if INS12 is not blank.

INS12 Insured Individual Death Date

Not Used

ID 1/35 Date of death of the Insured Individual in the format CCYYMMDD. Required if INS11 is not blank.

Subscriber Number

REF 1 Req Used to identify the subscriber using an ID code.


Req ID 2/3 Code qualifying the reference identification. 0F



PAGE 15-17

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



REF02 Subscriber Identifier

Req AN 1/30 The unique identifier of the subscriber associated with this member loop. (May be self) Social Security Number in the format 999-99-9999 or Alternate Key value agreed to by the Trading Partners


Member Policy Number

REF 1 Opt Allows the sender to designate a Group Number specific to the member. If the Transaction Set Policy Number segment was used in the same transaction, this can still be sent and will override the global specification for this member only. If no Transaction Set Policy Number segment is being sent, this segment will always be sent.


Req ID 2/3 Code qualifying the reference identification. 1L

REF02 Insured Group or Policy Number

Req AN 1/30 Sender's Group Number ? What value(s), if any, will be used?

Member Identification Number

REF 5 Opt Allows the sender to pass in additional identifying information about the member.



PAGE 15-18

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX




Req ID 2/3 Code qualifying the reference Identification. 17 - Client Reporting Category 23 - Client Number 3H - Case Number 60 - Cross Reference Number DX - Department/Agency Number F6 - Health Insurance Claim Number Q4 - Prior Identifier Number ZZ - Mutually Defined

? Which qualifiers, if any, will be used?

REF02 Subscriber Supplemental Identifier

Req AN 1/30 An identifier of the type specified in REF01. ? Sender designates which originating system field elements will be used with each qualifier.

Prior Coverage Months

REF 1 Opt Used to describe prior health coverage.


Req ID 2/3 Code qualifying the reference identification. QQ

REF02 Prior Coverage Month Count

Req AN 1/30 Number of months of prior health coverage.

Member Level Dates

DTP 20 Opt Used to pass a variety of dates based on member data in the originating system.



PAGE 15-19

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DTP01 Date Time Qualifier

Req ID 3/3 A code that qualifies the type of member level date. 286 - Retirement (Not used) 296 - Return To Work (Not used) 297 - Date Last Worked (Not used) 300 - Enrollment Signature Date 301 - Cobra Qualifying Event 303 - Maintenance Effective 336 - Employment Begin 337 - Employment End (Not used) 338 - Medicare Begin (Not used) 339 - Medicare End (Not used) 340 - COBRA Begin 341 - COBRA End 350 - Education Begin (Not used) 351 - Education End (Not used) 356 - Eligibility Begin 357 - Eligibility End 383 - Adjusted Hire (Not used) 393 - Plan Participation Suspension (Not used) 394 - Rehire (Not used) 473 - Medicaid Begin (Not used) 474 - Medicaid End (Not used)

DTP02 Date time Period Format Qualifier

Req ID 2/3 Date Time format. D8



PAGE 15-20

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DTP03 Status Information Effective Date

Req AN 1/35 The date associated with the code passed in DTP01. CCYYMMDD

Cobra related dates are sent if designated by the sender. All other dates not marked as "not used" are sent if corresponding data exists in the originating system.

Member Name NM1 1 Req Supplies the member's full name and Social Security Number.

NM101 Entity Identifier Code

Req ID 2/3 A code identifying whether this is the member's identifier information or a correction to the member's identifier information. IL - Insured or Subscriber

NM102 Entity Type Qualifier

Req ID 1/1 Code qualifying the type of entity. 1

NM103 Member Last Name

Req AN 1/35 Member Last Name.

NM104 Member First Name

Req AN 1/25 Member First Name.

NM105 Member Middle Name

Opt AN 1/25 Member Middle Name. Only the first character is used as Member Middle Initial.

NM106 Member Name Prefix

Not Used

AN 1/10 Member Name Prefix.



PAGE 15-21

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



NM107 Member Name Suffix

Opt AN 1/10 Member Name Suffix.

NM108 Identification Code Qualifier

Opt ID 1/2 A code that defines the structure for NM109.34

NM109 Subscriber Identifier

Opt AN 2/80 Social Security number in the format 999-99-9999.

Member Communications Numbers

PER 1 Opt Used to pass phone numbers associated with the member.

PER01 Contact Function Code

Req ID 2/2 Code identifying the contact type. IP

PER03 Communication Number Qualifier

Req ID 2/2 A code qualifying the type of communication number in PER04. HP - Home Phone Number WP - Work Phone Number.

PER04 Communication Number

Req AN 1/80 The communications number. Used for subscriber only. Not used for dependents.


Opt ID 2/2 A code qualifying the type of communication number in PER06. HP - Home Phone Number WP - Work Phone Number.


Opt AN 1/80 The communications number. Used for subscriber only. Not used for dependents.



PAGE 15-22

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



Member Residence Street Address

N3 1 Opt The resident address of a member. ? Verify with the sender on what specific address will be sent

N301 Member Address Line

Req AN 1/55 The first Address Line of the member.


Opt AN 1/55 The second Address Line of the member.

Member Residence City, State, Zip Code

N4 1 Opt The resident city, state, zip code, and county/area information of a member.

N401 Member City Name

Req AN 2/30 The City of the member.

N402 Member State Code

Req ID 2/2 The State of the member or subscriber.

N403 Member Postal Zone or Zip Code

Req ID 3/15 The Zip Code of the member or subscriber.

N404 Country Code Opt ID 2/3 The country code of the member or subscriber. Required only if the country is not the US.

N405 Location Qualifier Opt ID 1/2 A code that qualifies the location code in N406. 60 - Area (Not Used) CY - County (Only used if agreed to by Trading Partners) Required if N406 is used.




PAGE 15-23

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



N406 Location Identification Code

Opt AN 1/30 The county or area as specified by N405. ? Will this be sent?

Member Demographics

DMG 1 Opt Provides demographic information for the member. Required during initial enrollment of a member.

DMG01 Date Time Period Format Qualifier


DMG02 Member Birth Date

Req AN 1/35 Member Birth Date in the format CCYYMMDD.

DMG03 Gender Code Req ID 1/1 A code used to define the member's gender. F - Female M – Male

DMG04 Marital Status Code

Opt ID 1/1 A code used to define the member's marital status. B - Registered Domestic Partner D - Divorced I - Single M - Married R - Unreported S - Separated U - Unmarried W - Widowed X - Legally Separated Only used if agreed to by the trading partners.

? What value(s), if any, will be used?



PAGE 15-24

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DMG05 Race or Ethnicity Code

Opt ID 1/1 A code that defines the ethnicity of the member. 7 = Not provided 8 = Not Applicable A = Asian or Pacific Islander B = Black C = Caucasian D = Subcontinent Asian American E = Other Race or Ethnicity F = Asian Pacific American G = Native American H = Hispanic I = American Indian or Alaskan Native J = Native Hawaiian N = Black (non-Hispanic) O = White (non-Hispanic) P = Pacific Islander Z = Mutually Defined Sent only for the Subscriber and only if agreed to by the trading partners.

? What value(s), if any, will be used?

DMG06 Citizen Status Code

Opt ID 1/2 A code that defines whether the member is a U.S. citizen or not. 1 - U.S. Citizen 2 - Non-Resident Alien 3 - Resident Alien Sent only for the Subscriber and only if agreed to by the trading partners.

? What value, if any, will be used?

Member Income ICM 1 Opt Specifies information about the member's income. Only used when agreed to by the trading partners.



PAGE 15-25

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



ICM01 Frequency Code Req ID 1/1 Indicates the frequency or type of payment. 1 - Weekly 2 - BiWeekly 3 - Semimonthly 4 - Monthly 6 - Daily 7 - Annual 8 - Two Calendar Months 9 - Lump-sum Separation Allowance B - Year-to-date C - Single H - Hourly Q - Quarterly S - SemiAnnual U - Unknown

? What qualifier, if any will be used?

ICM02 Wage Amount Req R 1/18 The numeric figure associated with the Frequency Code received.


Member Language

LUI 5 Opt The member language(s) to be sent.

? Should only besubmitted when agreed to by trading partners.

LUI03 Language Description

Opt AN 1/80 The name of the language.

Member Mailing Address

NM1 1 1 Opt Allows specification of mailing address information.

? Verify with the sender on what specific address type, if any, will be sent



PAGE 15-26

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



NM101 Entity Identification Code

Req ID 2/3 Code that identifies the entity type. Always 31


Req ID 1/1 Code qualifying the type of entity. Always 1

Member Mail Street Address

N3 1 Opt The mailing address to be sent.

N301 Subscriber Address Line

Req AN 1/55 The first Address Line of the member.


Opt AN 1/55 The second Address Line of the member.

Member Mail City, State, Zip

N4 1 Opt Allows a mailing address to be sent.

N401 Subscriber City Name

Req AN 2/30 The City of the member.

N402 Subscriber State Code

Req AN 2/2 The State of the member.

N403 Subscriber Postal zone or Zip Code

Req AN 3/15 The Zip Code of the member.

N404 Country Code Opt ID 2/3 The country code of the member.

Health Coverage HD 99 1 Opt The coverage information of the member

HD01 Maintenance Type Code

Req ID 3/3 A code that is used to determine the action type for a coverage. 030 - Audit or Compare



PAGE 15-27

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



HD03 Insurance Line Code

Req ID 2/3 A code that identifies the line of coverage. AG - Preventive Care/Wellness AH - 24 Hour Care AJ - Medicare Risk AK - Mental Health DCP - Dental Capitation DEN - Dental EPO - Exclusive Provider Organization FAC - Facility HE - Hearing HLT - Health HMO - Health Maintenance Organization LTC - Long-Term Care LTD - Long-Term Disability MM - Major Medical MOD - Mail Order Drug PDG - Prescription Drug POS - Point of Service PPO - Preferred Provider Organization PRA - Practitioners STD - Short-Term Disability UR - Utilization Review VIS - Vision

? What qualifier(s), if any, will be used?

HD04 Plan Coverage Description

Opt AN 1/50 The Plan that the member is on. ? What value, if any, will be used?



PAGE 15-28

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



HD05 Coverage Level Code

Opt ID 3/3 A code that identifies the level of coverage. CHD - Children Only DEP - Dependents Only E1D - Employee and 1 dependent E2D - Employee and 2 dependents E3D - Employee and 3 dependents E5D - Employee and one or more dependentsE6D - Employee and 2 or more dependents E7D - Employee and 3 or more dependents E8D - Employee and 4 or more dependents E9D - Employee and 5 or more dependents ECH - Employee and Children EMP - Employee only ESP - Employee and Spouse FAM - Family IND - Individual SPC - Spouse and Children SPO - Spouse only TWO - Two Party

? What qualifier(s), if any, will be used?

Health Coverage Dates

DTP 4 Req Used to send dates related to the action specified in the Health Coverage segment.


Req ID 3/3 A qualifier that defines the type of health coverage date. 303 - Maintenance Effective 348 - Benefit Begin 349 - Benefit End

DTP02 Date time Period Format Qualifier

Req ID 2/3 Date Time format. Always D8



PAGE 15-29

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DTP03 Coverage Period Req AN 1/35 The date associated with the code passed in DTP01 in the format CCYYMMDD.

Provider Information

LX 30 1 Opt Used to provide information about providers of care when a managed care plan is in use.


LX01 Assigned Number Req N0 1/6 This is the loop number for provider specifications for this member. It should be sequential and the first instance should be 1.

Provider Name NM1 1 Req Used to identify a provider of care.

NM101 Entity Identifier Code

Req ID 2/3 A code used to determine the provider type. P3 - Primary Care Provider


Req ID 1/1 A code used to determine if the provider information on this segment refers to a person or non-person entity. 1 - Person 2 - Non-Person Entity

NM103 Provider Last or Organization Name

Opt AN 1/35 Last or Organization name. Must be used if NM109 is not provided. Cannot be used if NM109 is provided. Last Name if NM102 is 1. Organization Name if NM102 is 2. Used to help identify exact tin/sub tin for provider.

NM104 Provider First Name

Opt AN 1/25 First Name of the Provider. Used to help identify exact tin/sub tin for provider.

NM105 Provider Middle Name

Opt AN 1/25 Middle name of the provider. Used to help identify exact tin/sub tin for provider.



PAGE 15-30

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



NM106 Provider Name Prefix

Opt AN 1/10 Provider Name Prefix.

NM107 Provider Name Suffix

Opt AN 1/10 Provider Name Suffix. Used to help identify exact tin/sub tin for the provider.

NM108 Identification Code Qualifier

Opt ID 1/2 A code that defines the type of identifier in NM109. Required if NM109 is used. 34 - SSN FI - Federal Taxpayer's ID Number

NM109 Provider Identifier Opt AN 2/80 Appropriate identifier. Required if NM108 is supplied. Used to help identify the exact tin/sub tin for the provider.

NM110 Entity Relation Code

Req ID 2/2 A code that defines the member's relation to the provider. 25 - Established Patient 26 - Not Established Patient 72 - Unknown

Provider City, State, Zip Code

N4 1 Opt Provider address to be sent

N401 Provider City Name

Req AN 2/30 The City of the provider. May be used to help identify the exact tin / sub-tin for the provider.

N402 Provider State Code

Req ID 2/2 The State of the provider. May be used to help identify the exact tin / sub-tin for the provider.



PAGE 15-31

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



N403 Provider Postal Zone or Zip Code

Req ID 3/15 The Zip Code of the provider. May be used to help identify the exact tin/sub-tin for the provider.

N404 Country Code Opt ID 2/3 This field will be blank

N405 Location Qualifier Opt ID 1/2 A code that is used to qualify N406 CY - County

? Submitted only whenagreed to by trading partners.

N406 Location ID Code Opt AN 1/30 The area, county, or region as specified by N405. Populated if N405 is used.

Provider Communications Numbers

PER 2 Opt Allows provider communications numbers to be sent.

PER01 Contact Function Code

Req ID 2/2 Code that identifies the contact type. IC


Req ID 2/2 A code that defines the type of communication number that is in PER03. FX - Facsimile TE - Telephone


Req AN 1/80 The communication number.


Opt ID 2/2 A code that defines the type of communication number that is in PER06. FX - Facsimile TE - Telephone



PAGE 15-32

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX




Opt AN 1/80 The communication number.

Coordination Of Benefits

COB 5 1 Opt Coordination of Benefits information to be sent.


COB01 Payer Responsibility Sequence Number Code

Req ID 1/1 A code that defines the insurance carriers level of responsibility in paying a claim. P - Primary S - Secondary

COB02 Insured Group or Policy Number

Opt AN 1/30 Policy number.

COB03 Coordination of Benefits Code

Req ID 1/1 A value used to indicate what to do with Coordination of Benefits 1 - Coordination of benefits 6 - No Coordination of Benefits.

Other Insurance Company Name

N1 1 Opt Allows the insurance company to be identified.


Req ID 2/3 Code that identifies the entity type. IN

N102 Insurer Name Opt AN 1/60 Other insurance company name.

Coordination of Benefits Eligibility Dates

DTP 2 Opt Contains the dates for which COB is in effect.


Req ID 3/3 A code used to define the type of COB date. 344 - COB Begins 345 - COB Ends



PAGE 15-33

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



DTP02 Date Time Period Format Qualifier


DTP03 Coordination of Benefits Date

Req AN 1/35 The date associated with the code passed in DTP01 in the format CCYYMMDD.

Transaction Set Trailer

SE 1 Req Indicates the end of the transaction and lists the number of segments included within it.

SE01 Transaction Segment Count

Req N0 1/10 Total number of segments included in this transaction set including the header and trailer.

SE02 Transaction Set Control Number

Req AN 4/9 A unique number assigned by the sender.

Functional Group Trailer

GE 1 Req This segment indicates the end of a functional group and to provide control information.

GE01 Number of Transaction Sets Included

Req N0 1/6 Total number of transaction sets included in the functional group.

GE02 Group Control Number

Req N0 1/9 Assigned number originated and maintained by the sender.

Interchange Control Trailer

IEA 1 Req Defines the end of an interchange of zero or more functional groups and interchange-related control segments.

IEA01 Number of Included Functional Groups

Req N0 1/5 A count of the number of functional groups included in an interchange.



PAGE 15-34

SEGMENT NAME SEG ID

CODE

LOOP RPT

SEG RPT

EDI FIELD ID


DATA TYPE

MIN MAX



IEA02 Interchange Control Number

Req N0 9/9 A control number assigned by the interchange sender.

APPENDIX 15C. AE – ADMIN ELECTRONICS 834 COMPANION GUIDE -

PAGE 15-35

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Documents

Chapter 15C. AE – Administration Electronic - Zendesk · Chapter 15C. AE – Administration Electronic OVERVIEW This appendix contains all the field information for the Segment