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DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
1
___________________________________________
Delta Dental of Arizona HIPAA Transaction
Standard Companion Guide
Refers to the X12N Implementation Guide
005010X220: 834 – Benefit Enrollment and
Maintenance
Companion Guide Version Number: 5.3
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
2
EDITOR’S NOTE:
This Companion Guide is a work in-progress. Information found here may change over
time. Delta Dental of Arizona reserves the right to make changes to this Companion
Guide.
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
3
Table of Contents
Introduction 4
General EDI Terminology 5
ASC X12 Nomenclature 6
Header Segments 7
Trailer Segments 9
Data Clarifications for the 834 Transaction Set 10
Preferred Values for Elements 10
Segments Not Used by Delta Dental 17
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
4
Introduction
This document is the property of Delta Dental of Arizona and is intended to provide guidance in
implementing the ANSI ASC X12N Version 5010 Benefit Enrollment and Maintenance – 834
transaction. This ASC X12N 834 format is mandated by the Health Insurance Portability and
Accountability Act (HIPAA). This transaction is used to transfer enrollment information electronically
from the sponsor of the insurance coverage to a healthcare payer. Use of the 5010 version of the X12
standard is required by federal law. The compliance date for use of this standard is January 1, 2012.
There are required, as well as situational loops that each user must take into consideration in
determining the appropriate use for their transactions. It is recommended that each user develop
relevant business scenarios for their business uses of the 834, as the use of this transaction can vary
from user to user. As guidance, please refer to the Business Scenarios developed by ASC X12N
Insurance Subcommittee for the 834 transaction. These are located at:
www.wpc-edi.com
This document is based on the implementation standard of the ASC X12N Benefit Enrollment and
Maintenance – 834. It is meant to be a companion document and not a replacement for the ASC X12
834 implementation guide. Specific instructions contained in this document are provided for
clarification purposes only and should be used in conjunction with the applicable HIPAA
Implementation Guides published by Washington Publishing Company.
If you would like to view the implementation guide and the ASC X12 standards, please refer to the
documents published by the Washington Publishing Company for the ASC X12N Insurance
Subcommittee. The website for purchasing these documents is:
Store.x12.org
HIPAA regulations allow users to submit changes to the electronic transactions formats. To request
changes for consideration to the ASC X12 standards, please contact the HIPAA Designated Standards
Maintenance Organizations website at:
www.hipaa-dsmo.org
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
5
General EDI Terminology
A listing of terms commonly used throughout the HIPAA regulations and the EDI transactions is
available from WEDI. The website is:
www.wedi.org
Go to the Resources, Select HIPAA Resources and it will be found under the other HIPAA resources
section.
ANSI X12 834 v5010 – HIPAA standardized ANSI X12 transaction format for benefit enrollment and
maintenance.
Basic Character Set – The basic character set includes those characters selected from the uppercase
letters, digits, space, and specified characters such as: A…Z | 0…9 | ! | “ | & | ‘ | ( | ) | * | + | , | - | . | / | :
| ; | ? | = | space.
Data Segment – Corresponds to a record in data processing terminology. Consists of logically related
data elements in a defined sequence (defined by X12). Each segment begins with a segment identifier,
which is not a data element and one or more related data elements, which are preceded by a data
element separator. Each segment ends with a segment terminator.
Data Element – Corresponds to a field in data processing. They are assigned a unique reference
number. Each element has a name, description, type, minimum length and maximum length. The
length of an element is the number of character positions used.
EDI – An acronym for Electronic Data Interchange.
Electronic Data Interchange – the application-to-application transfer of key business information
transacted in a standard format using a computer-to-computer communications link.
Implementation guides – Documents that provide standardized data requirements and content as the
specifications for consistent implementation of a standard transaction set. HIPAA implementation
guides are published by the Washington Publishing Company on their website: www.wpc-edi.com.
Interface – The point at which two systems connect to pass data.
Loops – Loops are groups of semantically related segments. Data segment loops may be unbounded or
bounded.
Trading partners – Entities that exchange electronic data files. Agreements are sometimes made
between the partners to define the parameters of the data exchange and simplify the implementation
process.
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
6
X12 Transaction Set – A transaction set is considered one business document which is composed of a
transaction set header control segment, one or more data segments, and a transaction set trailer control
segment.
X12N – An Accredited Standards Committee (ASC) commissioned by the American National
Standards Institute (ANSI) to develop standards for Electronic Data Interchange (EDI). While X12
indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing EDI
standards for the insurance industry.
ASC X12 Nomenclature
The ASC X12 Nomenclature guide is a useful reference in understanding the details of the ASC X12
transactions. This includes hierarchical structure of the ASC X12 transactions, general definitions and
concepts, relations among control segments, functional groups, and HL structures. The ASC X12
Nomenclature guide is the same for all transactions. To review this guide, please refer to the website:
www.wpc-edi.com
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
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Header Segments
Interchange Control Header The ISA segment is the Interchange Header Segment. This segment identifies the sender and
receiver for each transaction. This segment also identifies the delimiters used throughout the
file.
Please use these values when sending the ISA segment:
Page # Loop Id Reference Name Length Value
C.4 n/a ISA01 Authorization Information
Qualifier
2/2 00
C.4 n/a ISA02 Authorization Information 10/10 Fill with 10 Spaces
C.4 n/a ISA03 Security Information Qualifier 2/2 00
C.4 n/a ISA04 Security Information 10/10 Fill with 10 Spaces
C.4 n/a ISA05 Interchange ID Qualifier 2/2 Groups ID qualifier
C.4 n/a ISA06 Interchange Sender ID 15/15 Group’s Tax ID or similar number (For
TPA’s, this must be a unique number for
each group that you send)
C.4 n/a ISA07 Interchange ID Qualifier 2/2 30
C.4 n/a ISA08 Interchange Receiver ID 15/15 860274899
C.6 n/a ISA15 Interchange Usage Indicator 1/1 T = Test for all test files
P = Production for all production files
For all other ISA elements, please refer to the HIPAA-AS implementation Guides for specific
instructions.
Functional Group Header The GS segment indicates the beginning of a functional group and provides control
information.
Please use these values when sending the GS segment:
Page # Loop Id Reference Name Length Value
C.7 n/a GS02 Application Sender’s Code 2/15 Use your Sender Id or the same value as
ISA06
C.7 n/a GS03 Application Receiver’s Code 2/15 DDAZ
For all other GS elements please refer to the HIPAA-AS implementation Guides for specific
instructions.
Transaction Set Header The ST segment indicates the start of a transaction set and assigns a control number.
For all ST elements please refer to the HIPAA-AS implementation Guides for specific
instructions.
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
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Sponsor Name - This segment identifies the sponsor.
Please use these values when sending the N1 segment in the 1000A loop:
Page # Loop Id Reference Name Length Value
39 1000A N101 Entity Identifier Code 2/3 P5
39 1000A N102 Name 1/60 Group or Employer’s Name
40 1000A N103 Identification Code Qualifier 1/2 24 or FI
40 1000A N104 Identification Code 2/80 Employer’s ID Number or Federal Tax ID
Payer - This segment identifies the payer.
Please use these values when sending the N1 segment in the 1000B loop:
Page # Loop Id Reference Name Length Value
41 1000B N101 Entity Identifier Code 2/3 IN
41 1000B N102 Name 1/60 DELTA DENTAL OF ARIZONA
42 1000B N103 Identification Code Qualifier 1/2 FI
42 1000B N104 Identification Code 2/80 860274899
TPA/Broker Name - This segment identifies the TPA/Broker if involved.
Please use these values when sending the N1 segment in the 1000C loop:
Page # Loop Id Reference Name Length Value
43 1000C N101 Entity Identifier Code 2/3 BO for Broker, TV for TPA
43 1000C N102 Name 1/60 Broker or TPA Name
44 1000C N103 Identification Code Qualifier 1/2 FI
44 1000C N104 Identification Code 2/80 Broker or TPA Federal Tax ID
DELTA DENTAL COMPANION GUIDE
October 1, 2010. 005010.5.3
9
Trailer Segments
Interchange Control Trailer The IEA segment identifies the end of an interchange of zero or more functional groups and
interchange-related control segments and is the last segment within the transaction set.
For all IEA elements please refer to the HIPAA-AS Implementation Guides for specific
instructions.
Functional Group Trailer
The GE segment indicates the end of a functional group and provides control information.
For all GE elements please refer to the HIPAA-AS implementation Guides for specific
instructions.
Transaction Set Trailer The SE segment indicates the end of a transaction set and provides the count of transmitted
segments.
For all SE elements please refer to the HIPAA-AS implementation Guides for specific
instructions.
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Data Clarifications for the 834 Transaction Set
Delta Dental would prefer to receive the basic character set
Preferred Values for Elements
Page # Loop Id Reference Name Codes Length Notes/Comments
48 2000 INS01 Yes/No Condition Response
Code – Insured Indicator
Y – Subscriber
N - Dependent
1/1
48 2000 INS02 Individual Relationship Code The preferred values for this are:
01 – Spouse
09 – Adopted Child
10 – Foster Child
15 – Ward
17 – Stepson or Stepdaughter
18 – Self (Subscriber)
19 – Child
23 – Sponsored Dependent
25 – Ex-Spouse
53 – Life Partner
2/2
49 2000 INS03 Maintenance Type Code 001 – Change
021 – Addition
024 – Cancellation or
termination
025 – Reinstatement
030 – Audit or Compare
3/3
49 2000 INS05 Benefit Status Code The preferred values for this are:
A – Active
C – COBRA
1/1
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
52 2000 INS07 COBRA Qualifying Event
Code
1 – Termination
2 – Reduction of work hours
3 – Medicare
4 – Death
5 – Divorce
6 – Separation
7 – Ineligible Child
8 – Bankruptcy of Retired
Employee’s former employer
9 – Layoff
10 – Leave of Absence
1/2 Required if member is enrolled in COBRA
52 2000 INS08 Employment Status Code AO – Active Military – Overseas
AU – Active Military – USA
FT – Full-time active employee
L1 – Leave of Absence
PT – Part-time Active Employee
RT – Retired
TE – Terminated
2/2 Required for subscriber
53 2000 INS09 Student Status Code The preferred values for this are:
F – Full-time
N – Not a Student
P – Part-time will be treated as
“Not a Student”
1/1
53 2000 INS10 Yes/No Condition or
Response – Handicap
Indicator
N – No individual is not
handicapped
Y – Yes individual is
handicapped
1/1
54 2000 INS12 Date Time Period 1/35 Date of death of the subscriber/dependent
55 2000 REF01 Reference Identification
Qualifier
0F – Subscriber Number 2/3 Required field for all members.
55 2000 REF02 Reference Identification 1/50 The Social Security number of the subscriber
or the Employee ID number supplied by the
employer. If both are required, use NM109
for the SSN. If SSN is required but EIN is
optional, use REF01 = DX for the EIN.
Numeric values only.
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
56 2000 REF01 Reference Identification
Qualifier
1L – Group Number 2/3 This should only be used for Dental only or
Vision only groups. Groups with both should
send in the 2300 loop.
56 2000 REF02 Reference Identification 1/50 The 18 digit Group Number assigned by Delta
Dental
59 2000 DTP01 Date/Time Qualifier 336 – Employment Begin (Hire Date)
350 – Education Begin (Student Start Date)
357 – Eligibility End (Termination
Date/Last Day of Coverage)
3/3
60 2000 DTP03 Date Time Period 1/35 Status Information Effective Date
62 2100A NM101 Entity Identifier Code 74 – If sending corrected identifier
information on already enrolled member
IL - If enrolling new member or updating
member with no change in identifying
information
2/3
63 2100A NM102 Entity Type Qualifier 1 – Person 1/1
63 2100A NM103 Name Last or Organization
Name
1/60 Member Last Name
63 2100A NM104 Name First 1/35 Member First Name
63 2100A NM105 Name Middle 1/25 Send if supplied
Member Middle Name
63 2100A NM107 Name Suffix 1/10 Send if supplied
Member Name Suffix
64 2100A NM108 Identification Code Qualifier 34 – Social Security Number 1/2 Send when required by X12 syntax
64 2100A NM109 Identification Code 2/80 Subscriber’s Social Security Number
65 2100A PER01 Contact Function Code IP – Insured Party 2/2 Send if supplied
65 2100A PER03/05/
07
Communication Number
Qualifier
EM – Electronic Mail (Email)
HP – Home Phone Number
TE – Telephone
WP – Work Phone Number
2.2 Send if supplied
65 2100A PER04/06/
08
Communication Number Insert the email or phone number here.
Please do not include any formatting in the
phone number. i.e. Send the phone number
as 5554443333
Send if supplied
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
68 2100A N301 Address Information 1/55 Required when enrolling subscriber, when
enrolling a dependent and the dependent’s
address is different from the subscriber’s
and when changing a member’s address.
Member Address Line 1
Please note that Delta Dental only stores the
first 30 characters of this field.
68 2100A N302 Address Information 1/55 Required if second address line exists
Member Address Line 2
Please note that Delta Dental only stores the
first 30 characters of this field.
69 2100A N401 City Name 2/30 Member City Name
69 2100A N402 State or Province Code 2/2 Member State Code
70 2100A N403 Postal Code 3/15 Member Postal Zone or Zip Code
70 2100A N404 Country Code 2/3 Required if country is not USA
71 2100A DMG02 Date Time Period 1/35 Required element. If not available, use
Delta Dental’s default - 19010101
Member Birth Date
72 2100A DMG03 Gender Code F – Female
M – Male
U – Unknown
1/1
86 2100B NM101 Entity Identifier Code 70 – Prior Incorrect Insured 2/3
87 2100B NM102 Entity Type Qualifier 1 – Person 1/1
87 2100B NM103 Name Last or Organization
Name
1/60 Incorrect Member Last Name
87 2100B NM104 Name First 1/35 Incorrect Member First Name
87 2100B NM105 Name Middle 1/25 Send if supplied Incorrect Member Middle Name
87 2100B NM107 Name Suffix 1/10 Send if supplied
Incorrect Insured’s Name Suffix
87 2100B NM108 Identification Code Qualifier 34 – Social Security Number 1/2 Send when required by X12 syntax
88 2100B NM109 Identification Code 2/80 Incorrect Subscriber’s Social Security
Number
90 2100B DMG02 Date Time Period 1/35 Required when there is a change to
previous demographic information
Incorrect Member Birth Date
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
90 2100B DMG03 Gender Code F – Female
M – Male
U – Unknown
1/1 Incorrect Member Gender Code
92 2100C NM101 Entity Identifier Code 31 – Postal Mailing Address 2/3 Send if mailing address is different from
residence address, dependent’s address is
different from the subscriber’s, or changing
member’s address
92 2100C NM102 Entity Type Qualifier 1 – Person 1/1
94 2100C N301 Address Information 1/55 Member Address Line 1
94 2100C N302 Address Information 1/55 Required if second address line exist
Member Address Line 2
95 2100C N401 City Name 2/30 Member City Name
95 2100C N402 State or Province Code 2/2 Member State Code
96 2100C N403 Postal Code 3/15 Member Postal Zone or Zip Code
96 2100C N404 Country Code 2/3 Required if country is not USA
106 2100E NM101 Entity Identifier Code M8 – Educational Institution 2/3
106 2100E NM102 Entity Type Qualifier 2 – Non-Person Entity 1/1
107 2100E NM103 Name Last or Organization
Name
1/60 School Name
140 2300 HD01 Maintenance Type Code 001 – Change
002 – Delete (incorrect coverage
record)
021 – Addition
024 – Cancellation/Termination
025 – Reinstatement
026 – Correction
030 – Audit or Compare
032 – Employee Information
Not Applicable
3/3 Required when enrolling a new member or
when adding, updating or removing
coverage
141 2300 HD03 Insurance Line Code DEN – Dental
VIS – Vision
2/3 Include a 2300 loop for each line of
insurance present.
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
142 2300 HD05 Coverage Level Code For 2 Tier:
EMP – Employee Only (S)
FAM – Family (F)
For 3 Tier:
EMP – Employee Only (S)
E1D – Employee and One Dependent (Child) (D)
ESP – Employee and Spouse (D)
E6D – Employee and Two or More Dependents (M)
For 4 Tier:
EMP – Employee Only (S)
ECH – Employee and Children (K)
ESP – Employee and Spouse (P)
FAM – Family (F)
For Composite:
FAM – Composite (T)
3/3 The preferred values are based on
the group contract.
143 2300 DTP01 Date/Time Qualifier 303 – Maintenance Effective (Change Date)
348 – Benefit Begin (Effective Date)
349 – Benefit End (Termination Date/Last Day of
Coverage)
3/3 Required when enrolling a member
or when there is a change to the
dates.
144 2300 DTP03 Date Time Period 1/35 Coverage Period
146 2300 REF01 Reference Identification
Qualifier
1L – Group Number 2/3 This should only be used for groups
with both Dental and Vision Groups
with only Dental or Only vision
should send in the 2000 loop.
147 2300 REF02 Reference Identification 1/50 The 18 digit Group Number assigned
by Delta Dental
164 2320 COB01 Payer Responsibility
Sequence Number Code
P – Primary
S – Secondary
T – Tertiary
1/1 Provide if available
164 2320 COB02 Reference Identification 1/50 Insured Group or Policy Number
164 2320 COB03 Coordination of Benefits
Code
1 – Coordination of Benefits
6 – No Coordination Of Benefits
1/1
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Page # Loop Id Reference Name Codes Length Notes/Comments
N/A 2500 FSA01 Maintenance Type Code 030 – Audit or Compare 3/3 Loop 2500 is for Flexible Spending
Plans only. If FSA does not apply
for a subscriber, omit this loop. If
the loop is present, FSA is present.
N/A 2500 FSA02 Flexible Spending Account
Selection Code
H – Healthcare 1/1
For all other elements, please refer to the HIPAA-AS implementation Guides for specific instructions.
DELTA DENTAL COMPANION GUIDE
January 1, 2011. 005010.5.3
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Segments Not Used by Delta Dental
Loop Segment ID Name Page Loop Segment ID Name Page
2100A EC Employment Class 76 2330 N3 Coordination of Benefits Related Entity Address 171
2100A ICM Member Income 79 2330 N4 Coordination of Benefits City, State, Zip 172
2100A AMT Member Policy Amounts 81 2330 PER Administrative Communications Contact 174
2100A HLH Member Health Information 82 2330 LS Additional Reporting Categories 176
2100A LUI Member Language 84 2710 LX Member Reporting Categories 177
2100D NM1 Member Employer 97 2750 N1 Reporting Category 178
2100D PER Member Employer Communications Numbers 100 2750 REF Reporting Category Reference 179
2100D N3 Member Employer Street Address 103 2750 DTP Reporting Category Date 181
2100D N4 Member Employer City, State, Zip 104 2750 LE Additional Reporting Categories Loop Termination 183
2100E PER Member School Communications Numbers 108
2100E N3 Member School Street Address 111
2100E N4 Member School City, State, Zip 112
2100F NM1 Custodial Parent 114
2100F PER Custodial Parent Communications Numbers 117
2100F N3 Custodial Parent Street Address 120
2100F N4 Custodial Parent City, State, Zip 121
2100G NM1 Responsible Person 123
2100G PER Responsible Person Communications Numbers 126
2100G N3 Responsible Person Street Address 129
2100G N4 Responsible Person City, State, Zip 130
2200 DSB Disability Information 137
2200 DTP Disability Eligibility Dates 139
2300 AMT Health Coverage Policy 145
2300 IDC Identification Card 150
2310 LX Provider Information 152
2310 NM1 Provider Name 153
2310 N3 Provider Address 156
2310 N4 Provider City, State, Zip Code 157
2310 PER Provider Communications Numbers 159
2310 PLA PCP Change Reason 162
2320 REF Additional Coordination of Benefits Identifiers 166
2320 DTP Coordination of Benefits Eligibility Dates 168
2330 NM1 Coordination of Benefits Related Entity 169