Oracle Extract

Functional Setup & Frequently Asked Questions (FAQ) for Setting Up the ANSI 834 System Extract [ID 246149.1]

Modified 29-MAR-2011 Type BULLETIN Status PUBLISHED

Applies to:

Oracle Advanced Benefits

Information in this document applies to any platform.

Purpose

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Functional Setup & FAQ for Setting Up the ANSI 834 System Extract

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Introduction

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Seeded system extracts are available as of the July 2002 Family Pack which provide standardized data requirements and content to users of version ANSI ASC X12.84, Benefit Enrollment and Maintenance (834).

The ANSI 834 is used to transfer enrollment and maintenance information, specifically for healthcare products from the sponsor of the insurance coverage, benefit or policy to a payee.

These new standards and code sets are part of the 1996 Health Insurance Portability and Accountability Act (HIPAA) administrative simplification procedures.

Although HIPAA does not mandate the electronic transmission of healthcare data, it does establish uniform national standards for all organizations electronically transferring healthcare enrollment and

maintenance information from the sponsor to a payee (carrier).

These standards comply with the National Electronic Data Interchange guidelines and define commonly used business transactions in a formal structure called 'transaction sets'.

The technical requirements were drawn from the National Electronic Data Interchange Transaction Set Implementation Guide for Benefit Enrollment and Maintenance - 834 (ASC X12N 834 004010 X095), published by

the Washington Publishing Company.

The system extract capabilities in Oracle HRMS 11i have been enhanced to accommodate any data element and sets that are needed to support ANSI 834.

Seeded extracts are delivered with the professional user interface and can be copied into and used by a specific business group.

The system provides the default setups of the ANSI 834 for a Full Profile Extract and a Change Event Extract. These setups can be modified based on your individual requirements after copying the seeded extract into

your business group.

Scope and Application

For more information regarding ANSI 834 standards, you may go to the Washington Publishing Company’s website at http://www.wpc-edi.com to obtain a copy of the National Electronic Data Interchange Transaction

Set Implementation Guide for Benefit Enrollment and Maintenance – 834

(ASC X12N 834 004010 X095).

Functional Setup & Frequently Asked Questions (FAQ) for Setting Up the ANSI 834 System Extract

Setting Up The ANSI 834 System Extract------------------------------------------------------------------------

The follow steps must be taken before attempting to use the ANSI 834 system extract.

(1) Enable Change Event Codes in your Business Group

1. Navigate to Other Definitions > Lookup Tables.

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2. In the Type field, query BEN_EXT_CHG_EVT.3. Click the Enabled boxes for the appropriate Event Codes. A full list of required Event Codes is listed below.4. Save your work.

Event Codes -----------Add Actual Termination Date Add BenefitAdd DependentAdd Mailing Address Add Period of Service Add Primary Address Add Primary Care ProviderChange Actual Termination DateChange of Approved Base Salary Change of Hire DateDelete Actual Termination DateDelete Mailing AddressDelete Primary AddressDelete Primary Care ProviderReinstate BenefitTerminate Benefit after CoverageTerminate Benefit before CoverageUpdate Assignment LocationUpdate Benefit OptionUpdate Coverage End DateUpdate Coverage Start DateUpdate Date Of BirthUpdate Date of DeathUpdate Disability StatusUpdate Email AddressUpdate Ethnic OriginUpdate Full NameUpdate GenderUpdate Mailing CityUpdate Mailing CountyUpdate Mailing Postal CodeUpdate Mailing StateUpdate Mailing StreetUpdate Marital StatusUpdate Opted for MedicareUpdate Person GradeUpdate Person LanguageUpdate Person Tobacco UsesUpdate Person’s PayrollUpdate Previous Last NameUpdate Primary AddressUpdate Primary Care Provider IDUpdate Primary Care Provider NameUpdate Primary Care Provider TypeUpdate Primary CityUpdate Primary CountryUpdate Primary Postal CodeUpdate Primary StateUpdate Primary StreetUpdate Social Security/National IdentifierUpdate Student StatusUpdate Termination ReasonUpdate Home PhoneUpdate Work PhoneUpdate Participant Monthly PremiumUpdate School or College


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(2) Copy the Extracts to your Business Group

1. Navigate to Mass Information eXchange: MIX > System Extract > Extract Definition.2. In the Extract Name field, query ANSI% in the Name field to find the ANSI-834 Full Profile and ANSI-834 Change Event. Note: This field is case sensitive.3. For the first extract, in the New Extract Prefix field, designate a prefix to precede your extract name.4. Click Copy Extract.5. Answer Yes when asked whether to continue copying the extract definition.6. Verification that your extract was successfully copied with the designated prefix will appear.7. Repeat the above steps for the second extract.

You can also verify that your extracts were saved by querying the Extract Name field you’re your designated prefix.

After Copying the Extracts to your Business Group, complete the below steps only for healthcare plans for which you will be using the ANSI extracts.

(3) Define Criteria to Extract Data for Specific Plans

1. Navigate to Mass Information eXchange: MIX > System Extract > Criteria Definition.2. Query your ANSI extracts – full and change only.3. Go to the Benefits tab for the full extract.4. For Criteria Type, select Enrollment Plan Name.5. Save your work.6. Repeat steps 3-5 for the other change extract.

(4) Change the Time Zone Element

The Time Zone element (BGN05) really only needs to be changed if the sender and the recipient of the extract are in different time zones. The PS (Pacific Standard) Time Zone has been set as the default Time Zone.

1. Navigate to Mass Information eXchange: MIX > System Extract > Layout Definition.2. Go to the Data Elements tab.3. Query ‘your prefix BGN05_00’ in the Name field.4. Change the Value to your 2-character Time Zone.5. Save your work.

(5) Define Policy Number, Broker Information & Sponsor Information

1. Navigate to Total Compensation > Programs and Plans > Plans > Details > Organizations.2. Select your first Organization from the list of values in the Organization field.3. Enter the Customer Identifier number.4. Enter the Policy or Group Number.5. Type in the Organization Role.6. Select the Organization Role Type.7. Repeat the above steps for each Organization for which you will use the ANSI extracts.8. Save your work.

(6) Decode Plan Name and Plan Option Name

Because ANSI standards have defined codes for the Plan Type and Option differ from Oracle Benefits standards, the Plan Name (HD03) and Plan Option Name (HD05) elements must be decoded.

Decode the Plan Name1. Navigate to Mass Information eXchange: MIX > System Extract > Layout Definition.2. Go to the Data Elements Tab3. Query the Plan Name that you copied, HD03.4. In the If Value Is field, select each healthcare Plan Name defined in your Business Group and enter the appropriate Code (as defined below) in the Replace With field. 5. Save your work.

Code Plan Type Description---- ---------------------AG Preventative Care/WellnessAH 24 Hour Care


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AJ Medicare RiskAK Mental HealthDCP Dental Capitation (DMO)DEN DentalEPO Exclusive provider organizationFAC FacilityHE HearingHLT Health HMO Health Maintenance OrganizationLTC Long Term CareLTD Long Term DisabilityMM Major MedicalMOD Mail Order DrugPDG Prescription DrugPOS Point of ServicePPO Preferred Provider OrganizationPRA PractitionersSTD Short Term DisabilityUR Utilization reviewVIS Vision

Decode the Option

1. Navigate to Mass Information eXchange: MIX > System Extract > Layout Definition.2. Go to the Data Elements Tab3. Query the Element Name that you copied, _HD05.4. In the If Value Is field, select each healthcare Option defined in your Business Group and enter the appropriate Code (as defined below) in the Replace With field. 5. Save your work.

Code Option Description---- ------------------IND Individual EMP Employee OnlyESP Employee and SpouseCHD Children OnlyDEP Dependents OnlyECH Employee and ChildrenFAM FamilySPC Spouse and ChildrenSPO Spouse OnlyTWO Two PartyE1D Employee and One DependentE2D Employee and Two DependentsE3D Employee and Three DependentsE5D Employee and One or More DependentsE6D Employee and Two or More DependentsE7D Employee and Three or More DependentsE8D Employee and Four or More DependentsE9D Employee and Five or more Dependents

(7) Decode Enrolled Life Event Name

Life event names are defined by Advanced Benefits Users and may vary between customers. Thus, they need to be decoded to meet ANSI standards for the Enrolled Life Event Name (INS04) element.

1. Navigate to Mass Information eXchange: MIX > System Extract > Layout Definition.2. Go to the Data Elements Tab3. Query the Enrollment Life Event Name that you copied, _INS04.4. Change the Type to Decoded Field.5. Search for Enrollment Life Event Name in the Field.6. In the If Value Is field, select each Life Event Name defined in your Business Group and enter the appropriate Code (as defined below) in the Replace With field.7. Save your work.


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Code Life Event Description---- ----------------------01 Divorce02 Birth03 Death04 Retirement05 Adoption06 Strike07 Termination of Benefits08 Termination of Employment09 COBRA10 COBRA Premium Paid11 Surviving Spouse14 Voluntary Withdrawal15 Primary Care Provider Change16 Quit17 Fired18 Suspended20 Active21 Disability22 Plan Change25 Change in Identifying Data Elements (Use this code when a change has been made to the primary elements that identify an individual such as first name, last name, SSN, DOB, employee ID number.)26 Declined Coverage27 Pre-Enrollment28 Initial Enrollment29 Benefit Selection31 Legal Separation32 Marriage33 Personnel Data (Use this code for any data change that is not included into any other allowed codes. I.e. Change in Coordination of Benefits information).37 Leave of Absence with Benefits38 Leave of Absence without Benefits39 Lay Off with Benefits40 Lay Off without Benefits41 Re-enrollment43 Change of Location (Use this for change of address.)AI No reason givenXN Notification OnlyXT Transfer

(8) Set up the Interchange Header & Trailer

The Interchange Header and Trailer are used to identify the start and end of a transmission of zero or more Functional Groups of information. All data must be enveloped within the Interchange Header and Footer before electronic transmission can occur.

Interchange Control Header (ISA)

The ISA record must be of a fixed length. Therefore, all elements within the ISA record must also be of a fixed length as indicated below in the Required Length column. Where no default data exists, the element value is seeded with spaces, illustrated by “.” below.

1. Element Field Name: Authorization Information Qualifier Element Name: ISA01 Required Length: 2 Default Value: 00 Optional Setup Instructions: “00” represents that no authorization information is present in ISA02. If an additional data identifier is present in ISA02, ISA01 should be changed to “03” which means “Additional Data Identification.”

2. Element Field Name: Authorization Information Element Name: ISA02 Required Length: 10 Default Value: ..........


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Optional Setup Instructions: Used for additional identification or authorization of the interchange sender or data in the interchange. If using an additional identifier, enter it here.

3. Element Field Name: Security Information Qualifier Element Name: ISA03 Required Length: 2 Default Value: 00 Optional Setup Instructions: “00” represents that no security password is defined in ISA04.

4. Element Field Name: Security Information Element Name: ISA04 Required Length: 10 Default Value: .......... Optional Setup Instructions: A password may be defined to identify security information about the interchange sender or data in the interchange. If a password is being used, enter it here.

5. Element Field Name: Interchange ID Qualifier Element Name: ISA05 Required Length: 2 Default Value: 30 Optional Setup Instructions: Qualifies the sender in ISA06. If you wish to use some other qualifying data than your TIN, change the element value to your choice below. 01 – Dun (D&B) 14 – Duns plus suffix20 – Health industry number (HIN) 27 – Carrier ID Number as assigned by HCFA 28 – Fiscal Intermediary ID number as assigned by HCFA 29 – Medicare provider and supplier ID number as assigned by CFA 30 – US Federal TIN 33 – National Assn of Insurance Commissioners Company Code (NAIC) ZZ - Mutually defined

6. Element Field Name: Interchange Sender ID Element Name: ISA06 Required Length: 15 Default Value: ............... Optional Setup Instructions: If your organization Tax ID number has been defined in Total Compensation > Plan > Details > Organization, this number will be defaulted into ISA06. If no TIN has been defined, enter it here and pad it with spaces to ensure that the element is 15 characters; otherwise, select which type of qualifying data you wish to use.

7. Element Field Name: Interchange ID Qualifier Element Name: ISA07 Required Length: 2 Default Value: .. Optional Setup Instructions: Qualifies the receiver in ISA08. The list of values is the same as in ISA05. Select the appropriate qualifier code or leave the element as 2 spaces.

8. Element Field Name: Interchange Sender ID Element Name: ISA08 Required Length: 15 Default Value: ............... Optional Setup Instructions: ID code published by the data receiver. When sending data, this ID is used as the sender ID. If a receiver ID is known, enter it here and pad it with spaces to ensure that it is 15 characters.

9. Element Field Name: Interchange Control Number Element Name: ISA13 Required Length: 9 Default Value: ......... Optional Setup Instructions: Control number assigned by the sender. ISA13 must be identical to IEA02.

10. Element Field Name: Acknowledgment Requested


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Element Name: ISA14 Required Length: 1 Default Value: . Optional Setup Instructions: Enter a “0” if no interchange acknowledgment is requested, or a “1” if an interchange acknowledgment is desired.

11. Element Field Name: Acknowledgment Requested Element Name: ISA15 Required Length: 1 Default Value: P Optional Setup Instructions: “P” represents production data that is to be processed. If sending test data only, change this value to “T”.

Interchange Group Trailer (IEA)

Element Field Name: Number of Included Functional GroupsElement Name: IEA01Default Value: 1Optional Setup Instructions: If more than 1 Functional Group of data is in the same interchange, change the element value to indicate how many Functional Groups are included.

(9) Set up the Functional Group Header & Trailer

The Ansi 834 is just one of several Functional Group of information that may be sent electronically. Oracle only seeds the extracts to send 834 – Benefits Enrollment & Maintenance information.

Functional Group Header (GS)

1. Element Field Name: Interchange Control Number Element Name: GS01 Default Value: BE Optional Setup Instructions: “BE” indicates that 834 Benefits Enrollment & Maintenance data is being sent. If using this seeded extract to send other non-834 data, this code must be changed to the appropriate Functional Identifier Code.

2. Element Field Name: Application Senders Code Element Name: GS02 Default Value: null Optional Setup Instructions: This code identifies the sender and is agreed upon by trading partners. If you have an agreed upon code, you may enter it in this field. Maximum field length is 15 characters.

3. Element Field Name: Application Receiver’s Code Element Name: GS03 Default Value: null Optional Setup Instructions: This code identifies the receiver and is agreed upon by trading partners. This is used as an additional identification or authentication. If you have an agreed upon code, you may enter it in this field. Maximum field length is 15 characters.

4. Element Field Name: Group Control Number Element Name: GS06 Default Value: null Optional Setup Instructions: This number is assigned by the sender. GS06 must be identical to the Group Control Number (GE02) in the Functional Group Trailer. The extract has been designed so that any value entered in GS06 will be copied into GE02.

Functional Group Trailer (GE)

Element Field Name: Number of Transaction Sets IncludedElement Name: GE01Default Value: 1Optional Setup Instructions: If sending more than 1 Transaction Set is included in the Functional Group or Interchange group terminated by the trailer containing this data element, change the data element to the appropriate number.


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After completing steps 1 through 9, the ANSI system extract setup is complete.

Sample ANSI Extract Outputs------------------------------------------------------------------------

Sample extracts are available from Chapter 4 of the National Electronic Data Interchange Transaction Set Implementation Guide for Benefit Enrollment and Maintenance – 834 (ASC X12N 834 004010 X095), pages 159-163.

Each line in the extract is called a Segment and each Segment begins with a Record code (ie. ST) which identifies the type of information contained in the Segment. Please refer to the above referenced document for a full list of Record definitions and seeded values in order to decipher the below examples. Based on the business scenario described in the above referenceddocument, the sample outputs are what you can expect to see when running the ANSI Change Extract.

Frequently Asked Questions------------------------------------------------------------------------

1. When do I use the Full Extract? When you send an electronic transmission of complete enrollment information for a new participant or group of participants, the Full Extract should be used.

2. When do I use the Change Extract? When you send an electronic transmission of maintenance information that updates the data for an existing participant or group of participants, the Change Extract should be used.

3. How do I test my extract to make sure that it works? You can run the Full or Change extracts for a sample set of data and send it to your healthcare provider as a test run. Just define ISA15 to “T” in the Interchange Header record to indicate that the transmission is a test. The recipient of the data can then inform you of any errors in the data or format of the transmission.

4. Can I send my premium payment and enrollment information in one transmission? Maybe. General Ansi standards allow you to send more than one Functional Group of information in one transmission. However, the Oracle Benefits only provides the Ansi 834 extracts to extract enrollment and maintenance information.

5. What is the data hierarchy and structure of the interchange? The communications envelope is illustrated below. There can be multiple transaction sets within one functional group and multiple functional groups within the interchange.

ISA – Interchange Control HeaderGS – Functional Group Header

ST – Transaction Set HeaderDetail Segments

SE – Transaction Set TrailerGE – Functional Group Trailer

ISE – Interchange Control Trailer

6. Who should use these extracts to send enrollment and maintenance information to healthcare providers? Customers sending enrollment and maintenance information via an electronic transmission or if mandated by the healthcare provider are required to comply with Ansi 834 standards.

7. Can I send other healthcare information electronically? Oracle Benefits only seeds the extracts for the electronic transmission of enrollment and maintenance data as this is the information that Standard and Advanced Benefits supports. Sending other healthcare information electronically may require a translation software or a similar extract creation by the software applications provider who maintains that data for you.

8. Where can I get more information on the HIPAA requirements? Go to the Washington Publishing Company’s website at http://www.wpc-edi.com to obtain a copy of the National Electronic Data Interchange Transaction Set Implementation Guide for Benefit Enrollment and Maintenance – 834 (ASC X12N 834 004010 X095).


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9. How do I know what type of data the different data segment IDs represent? Page 21 of the National Electronic Data Interchange Transaction Set Implementation Guide for Benefit Enrollment and Maintenance – 834 (ASC X12N 834 004010 X095) provides a list of segment ID’s and names.

10. Where can I find definitions of the various EDI terms such as Transaction Set, Functional Group, Segment, etc.? Section A of the National Electronic Data Interchange Transaction Set Implementation Guide for Benefit Enrollment and Maintenance – 834 (ASC X12N 834 004010 X095) provides a list of ASC X12 nomenclature and definitions.

11. If I do not send any healthcare data electronically to the provider, do I need to be concerned with these extracts? No

Related

Products

Oracle E-Business Suite > Human Capital Management > Benefits > Oracle Advanced Benefits

Keywords

BENEFITS; COBRA; CRITERIA; EXTRACT CRITERIA; EXTRACT DEFINITION; FREQUENTLY ASKED QUESTIONS; SYSTEM EXTRACT; TECHNICAL REQUIREMENTS

Errors

INS-04; INS-4

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