Comments
Description
Transcript
Michigan Department of Community Health
Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance Medicaid Health Plans 4976 Audit File and 5790 Daily File Version Date April 7, 2015 Effective April 25, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Table of Contents Introduction .............................................................................................................................................................................. 1 Transaction Description ............................................................................................................................................................ 2 Download Notes for ANSI ASC X12 834 Benefit Enrollment and Maintenance ............................................................................ 2 ANSI ASC X12 834 Benefit Enrollment and Maintenance Companion Guide Rules ..................................................................... 4 Interchange Control Header and Trailer ................................................................................................................................. 4 Transaction Set..................................................................................................................................................................... 7 Supplementary Information ..................................................................................................................................................... 18 Appendix A: Crosswalk for Maintenance Reason Code (2000 INS04) ................................................................................... 18 Appendix B: Crosswalk for Medicare Plan Code (2000 INS06-1)........................................................................................... 20 Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05-1) .................................................................................. 21 Appendix D: MAGI Category Indicator (2300 REF17) ......................................................................................................... 211 Revision Log .......................................................................................................................................................................... 22 Michigan Department of Community Health http://www.michigan.gov/mdch Page i Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Introduction This document is the property of the Michigan Department of Community Health (MDCH). The information contained in this document is for the use of Trading Partners engaging in electronic data interchange (EDI) health care transactions with the State of Michigan’s Community Health Automated Medicaid Payment System (CHAMPS). This document is intended as a companion to the 005010X220 • 834 Benefit Enrollment and Maintenance Technical Report 3 (TR3) dated August 2006. It also includes the changes to be found in the following TR3 Errata documents: • • Errata 005010X220E1 • 834 Benefit Enrollment And Maintenance TR3 dated January 2009 Errata 005010X220A1 • 834 Benefit Enrollment And Maintenance TR3 dated June 2010 The TR3 documents replace the 4010A1 Implementation Guide and related Addenda. The 5010 TR3 and related Errata documents can be downloaded from the Washington Publishing Company web site at http://www.wpc-edi.com/content/view/817/1. This document is expected to be used in conjunction with the TR3 and related Errata for the 834 transaction. The content of this document follows the guidelines authorized in the version modifications to the Health Insurance Portability and Accountability Act (HIPAA) Final Rule transaction standards published in the Federal Register January 16, 2009. This document provides MDCH-specific instructions regarding certain elements within the TR3 but does not change, supersede, or add to the definitions, data conditions, or use of data elements or segments in the standard. This document provides MDCH rules regarding: • • Identifiers to use when a national standard has not been adopted Parameters in the TR3 and related Errata that provide options In order to successfully download HIPAA transactions from the CHAMPS system, it is necessary to comply with the information contained in the MDCH Electronic Submission Manual Dated June 2013. The most current version of this manual can be downloaded from the MDCH web site at the following location: http://www.michigan.gov/documents/mdch/ESM_ACA_CORE_201308-01_V1_0_430365_7.pdf Michigan Department of Community Health http://www.michigan.gov/mdch Page 1 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Transaction Description The 834 is used to transfer enrollment information from the sponsor of the insurance coverage, benefits, or policy to a payer. Information transmitted includes initial enrollment and subsequent maintenance of individuals who are enrolled in CHAMPS. Download Notes for ANSI ASC X12 834 Benefit Enrollment and Maintenance The 834 transaction can be downloaded from the Data Exchange Gateway (DEG) in two formats, either ASCII or binary formats. When downloading to ASCII, files will include line feeds. These control which characters will appear after each segment, and will function as carriage returns. However, downloading to binary eliminates the use of line feeds. Please refer to the MDCH Electronic Submission Manual for information regarding: • • Interaction with the MDCH’s Data Exchange Gateway (DEG) Modes of retrieval (ASCII and binary formats) including Line Feed information This document includes clarifications for the following information: • • • • Interchange control header and trailer Functional group header and trailer 834 transaction set header and trailer Detail segments and elements of the 834 transaction itself The interchange control header and trailer (ISA and ISE) are presented together in the first section of this document. The functional group header and trailer (GS and GE) are presented together in the second section of this document. The 834 transaction set header and trailer (ST and SE) are presented with the detail 834 segments and elements in the third section. Three appendices follow the detailed data clarifications; they contain crosswalks of elements cited in the data clarification comments. Supporting Appendices: • • • • Appendix A: Crosswalk for Maintenance Reason Code (2000 INS04) Appendix B: Crosswalk for Medicare Plan Code (2000 INS06) Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05) Appendix D: MAGI Category Indicator (2300 REF17) Michigan Department of Community Health http://www.michigan.gov/mdch Page 2 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 This document uses several text conventions to distinguish MDCH data elements from the HIPAA TR3 data elements. The following table lists the text conventions used in this document: Convention Used <> “” () Light yellow shading Explanation Text included within < > describes what will be transmitted by MDCH. This could be the MDCH data element name or value, or, if blank, will display <spaces>. Text with “ ” around a value represents HIPAA TR3 values. The HIPAA TR3 description of the value in quotes, described above, is provided parenthetically. Light yellow shading indicates items changed in this revision of the Companion Guide Michigan Department of Community Health http://www.michigan.gov/mdch Page 3 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 ANSI ASC X12 834 Benefit Enrollment and Maintenance Companion Guide Rules Interchange Control Header and Trailer Loop ID Segment ID Data Element ID ISA ISA01 ISA ISA02 Loop/Segment/Element Name Loop – Interchange Control Header Segment – Interchange Control Header Authorization Information Qualifier Authorization Information ISA ISA ISA ISA ISA03 ISA04 ISA05 ISA06 Security Information Qualifier Security Information Interchange ID Qualifier Interchange Sender ID ISA ISA ISA07 ISA08 Interchange ID Qualifier Interchange Receiver ID ISA ISA09 Interchange Date “00” (No Security Information Present) <10 Spaces> “ZZ” (mutually defined) Positions 1-6, <D00111> Positions 7-15, <spaces> “ZZ” (Mutually Defined) Positions 1-4, <service bureau ID> Positions 5-15 <spaces> <interchange date>, in YYMMDD format ISA ISA10 Interchange Time <interchange time>, in HHMM format ISA ISA11 Repetition Separator “^” ISA ISA12 Interchange Control Version Number <00501> ISA Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules “00” (No Authorization Information Present) <10 Spaces> Page 4 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Segment ID ISA Data Element ID ISA13 Loop/Segment/Element Name Interchange Control Number ISA ISA ISA ISA14 ISA15 ISA16 IEA IEA01 IEA IEA02 Acknowledgment Requested Interchange Usage Indicator Component Element Separator Loop – Interchange Control Trailer Segment – Interchange Control Trailer Number of Included Functional Groups Interchange Control Number GS01 GS02 GS03 GS04 GS05 GS06 Loop – Functional Group Header Segment – Functional Group Header Functional Identifier Code Application Sender’s Code Application Receiver’s Code Date Time Group Control Number IEA GS GS GS GS GS GS GS Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules <interchange control number> MDCH will transmit identical interchange control numbers in ISA13 and IEA02 for a single interchange envelope. “0” (no acknowledgment requested) “P” (Production) or “T” (test) <:> <total number of functional groups> included within an interchange <interchange control number> MDCH will transmit identical interchange control numbers in ISA13 and IEA02 for a single interchange envelope. “BE” (benefit enrollment and maintenance, 834) <D00111> <service bureau ID> <functional group creation date> in CCYYMMDD format <functional group creation time> in HHMM format <data interchange control number> MDCH will transmit identical data interchange control numbers in GS06 and GE02 for a single functional group. Page 5 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Segment ID GS GS Data Element ID GS07 GS08 GE GE GE01 GE GE02 Michigan Department of Community Health http://www.michigan.gov/mdch Loop/Segment/Element Name Responsible Agency Code Version/Release/Industry Identifier Code Loop – Functional Group Trailer Segment – Functional Group Trailer Number of Transaction Set Included Group Control Number Companion Guide Rules “X” (Accredited Standards Committee X12) <005010X220A1> <total number of transaction sets>, included in the functional group or interchange <data interchange control number> MDCH will transmit identical data interchange control numbers in GS06 and GE02 for a single functional group. Page 6 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Transaction Set Loop ID Segment ID Data Element ID ST ST ST02 BGN Loop/Segment/Element Name Loop – Transaction Set Header Segment - Transaction Set Header Transaction Set Control Number Segment – Beginning Segment Transaction Set Purpose Code BGN BGN01 BGN BGN02 Reference Identification BGN BGN06 Reference Identification BGN BGN08 Action Code DTP Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules <transaction set control number> MDCH will assign a unique number within the transaction set, to indicate the start of the transaction. MDCH will transmit identical transaction set control numbers in ST02 and SE02. “00” (original and resubmission of original upon request of trading partner) “15” (re-submission to correct an error on original transmission) <XXXXCCYYMMDD TT> Where <XXXX> is the DCH file number (4976 or 5790); <CCYYMMDD> is the batch number; <2 spaces>; <TT> is the Transaction Set Purpose Code from BGN01 <cross reference to previous transaction> Not transmitted when BGN01 is “00”; if BGN01 is “15” will transmit the original transaction set reference number from BGN02. If BGN = “00” and file #5790, “2” (Change, Update) If BGN = “00” and file # 4976, “4” (Verify) If BGN=“15”, “RX” Segment – File Effective Date Page 7 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Segment ID DTP Data Element ID DTP01 Loop/Segment/Element Name Date/Time Qualifier DTP DTP03 Date Time Period QTY 1000A 1000A 1000A 1000A 1000A 1000B 1000B 1000B 1000B 1000B 2000 QTY QTY QTY01 QTY02 N1 N1 N1 N1 N102 N103 N104 N1 N1 N1 N1 N102 N103 N104 2000 INS 2000 INS INS01 2000 INS INS02 Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules “007” (effective) for a full file audit (file # 4976) “303” (maintenance effective) for an update transaction (files # 5790) Files # 4976 = first day of report month; file # 5790 = file run date Segment – Transaction Set Control Totals Quantity Qualifier Quantity Loop – Sponsor Name Segment – Sponsor Name Name Identification Code Qualifier Identification Code Loop – Payer Segment – Payer Name Name Identification Code Qualifier Identification Code Loop - Member Level Detail Segment – Member Level Detail Yes/No Condition or Response Code Individual Relationship Code “TO” (Total) <Total number of records transmitted in ST-SE loop> <Department of Community Health> “FI” (Federal Taxpayer’s Identification Number) <386000134> <Plan Name> “FI” (Federal Taxpayer’s Identification Number) <Plan Federal Taxpayer ID Number> “Y” (yes) – insured is always the subscriber “18” (self) – insured is always the subscriber Page 8 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Data Element ID INS03 Loop/Segment/Element Name Maintenance Type Code Companion Guide Rules 2000 Segment ID INS 2000 INS INS04 Maintenance Reason Code 2000 2000 2000 INS INS INS INS05 INS06-1 INS08 Benefit Status Code Medicare Plan Code Employment Status Code 2000 2000 INS REF INS12 2000 REF REF01 2000 2000 REF REF REF02 2000 REF REF01 2000 REF REF02 Date Time Period Segment – Subscriber Identifier Reference Identification Qualifier Reference Identification Segment – Member Policy Number Reference Identification Qualifier Reference Identification “XN” (notification only; file # 4976) File # 5790 values in Appendix A - Crosswalk for Maintenance Reason Code “A” (Active) Refer to Appendix B - Medicare Plan Code Crosswalk “AC” (active) for enrolled members “TE” (terminated) for disenrolled members <recipient date of death> when available and applicable 2000 REF 2000 REF REF01 2000 REF REF02 Michigan Department of Community Health http://www.michigan.gov/mdch Segment – Member Supplemental Identifier Reference Identification Qualifier Reference Identification “030” (audit or compare; file # 4976) “024” (cancellation or termination); “021” (addition); “001” (demographic or other change); “025” (benefit plan change) file 5790 “0F” (Subscriber Number) <beneficiary ID> Right-justified, zero-filled (RJ0F) “1L” (Group or Policy Number) <provider ID> Plan’s Provider ID – 12 Digits, leading zero filled “3H” (Case Number) <Case Number> Page 9 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Data Element ID 2000 Segment ID REF 2000 REF REF01 2000 REF REF02 Loop/Segment/Element Name Segment – Member Supplemental Identifier Reference Identification Qualifier Reference Identification 2000 DTP 2000 DTP DTP01 Segment – Member Level Dates Date/Time Qualifier 2000 DTP DTP03 Date Time Period 2100A 2100A 2100A NM1 NM1 NM101 Loop – Member Name Segment – Member Name Entity Identifier Code 2100A 2100A NM1 NM1 NM102 NM103 2100A NM1 NM104 Entity Type Qualifier Name Last or Organization Name Name First 2100A 2100A 2100A 2100A NM1 NM1 NM1 NM1 NM105 NM107 NM108 NM109 Name Middle Name Suffix Identification Code Qualifier Identification Code Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules “6O” (Cross Reference Number) when applicable on file #5790 <mother’s beneficiary ID> for newborns, when applicable on file # 5790 “356” (eligibility begin) for new enrollment Note: Termination of coverage will be communicated in the 2300 DTP loop. <enrollment begin date> “74” for demographic change; “IL” (Insured or Subscriber) for all others “1” (Person) <member last name> <member first name> If member first name is missing, MDCH will transmit <Unknown>. <member middle name> when available <member name suffix> when available “34” (Social Security Number) when available <member SSN> Page 10 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Data Element ID 2100A Segment ID PER 2100A 2100A PER PER PER01 PER03 2100A PER PER04 Loop/Segment/Element Name Segment – Member Communications Numbers Contact Function Code Communication Number Qualifier Communication Number 2100A 2100A PER PER PER05 PER06 Contact Function Code Communication Number 2100A N3 2100A N3 N301 Segment – Member Residence Street Address Address Information 2100A 2100A N3 N4 N302 2100A 2100A 2100A N4 N4 DMG N405 N406 2100A DMG DMG05 -1 Address Information Segment – Member Residence City, State, Zip Code Location Qualifier Location Identifier Segment – Member Demographics Race or Ethnicity Code 2100A ICM 2100A 2100A ICM ICM ICM01 ICM02 Segment - Member Income Frequency Code Monetary Amount Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules “IP” (Insured Party) “TE” (Telephone) <Case Telephone Number> when available on interface from Department of Human Services (DHS) “EM” (Electronic Mail) <Member E-Mail Address> when available on interface from DHS <Subscriber Address> If Subscriber Address is missing, and city, state, zip are present, MDCH will transmit <Unknown> for subscriber address. <Subscriber Address> “CY” (county/parish) <county code> Refer to Appendix C - Crosswalk for Race or Ethnicity Code “7” (Annual) Annual income (7 numeric digits, no decimal) Page 11 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID 2100A 2100A Segment ID ICM ICM Data Element ID ICM03 ICM05 Loop/Segment/Element Name Quantity Salary Grade 2100A LUI 2100A 2100A LUI LUI LUI01 LUI02 2100A 2100B LUI LUI04 2100B NM1 2100B 2100B 2100B NM1 NM1 NM1 NM101 NM102 NM103 2100B NM1 NM104 2100B 2100B 2100B NM1 NM1 DMG NM108 NM109 2100B 2100B 2100G DMG DMG DMG02 DMG03 Segment – Member Language Identification Code Qualifier Identification Code Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules Group Composition (2 numeric digits, no decimal) Federal Poverty Level (3 numeric digits, right-justified, zero-filled, no decimal) Use of Language Indicator Loop – Incorrect Member Name Segment – Incorrect Member Name Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Identification Code Qualifier Identification Code Segment –Incorrect Member Demographics Date of Birth Gender Loop – Responsible Person “LE” (ISO 639 Language Codes) MDCH will use the ISO 639-1 version of the ISO 639 language codes. “7” (Language Speaking) “74” (Prior Incorrect Insured) “1” (Person) <previous (incorrect) member last name> <previous (incorrect) member first name> If member first name is missing, MDCH will transmit <Unknown>. “34” (Social Security Number) when available <previous (incorrect) member SSN> <previous (incorrect) date of birth> <previous (incorrect) gender> Page 12 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Data Element ID 2100G Segment ID NM1 Loop/Segment/Element Name Segment – Responsible Person Entity Identifier Code 2100G NM1 NM101 2100G NM1 NM103 2100G 2100G 2100G 2100G NM1 NM1 NM1 PER NM104 NM105 NM107 2100G PER PER03 2100G PER PER04 2100G PER PER05 2100G PER PER06 Communication Number Qualifier Communication Number Name Last or Organization Name Name First Name Middle Name Suffix Segment – Responsible Person Communications Numbers Communication Number Qualifier Communication Number 2300 2300 HD 2300 HD HD01 Loop – Health Coverage Segment – Health Coverage Maintenance Type Code 2300 HD HD03 Insurance Line Code Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules “GD” (guardian) “QD” (responsible party) <Guardian Last Name>, or <Case Last Name> <Guardian First Name>, or <Case First Name> <Guardian Middle Name>, or <Case Middle Name> <Guardian Suffix>, or <Case Suffix> “TE” (Telephone) <Guardian or Responsible Party Telephone Number> when available on interface from Department of Human Services (DHS) “EM” (Electronic Mail) <Guardian or Responsible Party E-Mail Address> when available on interface from DHS “030” (audit or compare; file # 4976) “021” (addition) ; “024” (cancellation or termination); “001” (demographic changes); “”025” (benefit plan) file#5790) “HMO” (health maintenance organization) for MHP Page 13 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID 2300 Segment ID HD Data Element ID HD04 Loop/Segment/Element Name Plan Coverage Description 2300 2300 HD DTP HD05 2300 2300 DTP DTP DTP01 DTP02 2300 2300 2300 DTP DTP DTP DTP03 DTP01 DTP02 2300 DTP DTP03 Coverage Level Code Segment – Health Coverage Dates Date/Time Qualifier Date Time Period Format Qualifier Date Time Period Date/Time Qualifier Date Time Period Format Qualifier Date Time Period 2300 REF 2300 REF REF01 Michigan Department of Community Health http://www.michigan.gov/mdch Companion Guide Rules Transmitted to indicate if maternal support services (MSS) are required. <Y> MSS required <N> MSS not required “IND” (Individual) “348” (Benefit Begin) “D8” (Date Expressed in Format CCYYMMDD) <enrollment begin date> “349” (Benefit End) “D8” (Date Expressed in Format CCYYMMDD) <enrollment end date> when terminating coverage for a member Segment – Health Coverage Policy Number Reference Identification Qualifier “17” (Client Reporting Category) Page 14 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID 2300 Segment ID REF Data Element ID REF02 2320 Loop/Segment/Element Name Reference Identification Companion Guide Rules <client reporting category> The client reporting category will include concatenated <program code, level of care, scope, coverage, foster care status, BMP status, pharmacy restriction status, MAGI indicator, “parent flag” for HMP population, redetermination date in CCYYMMDD format>. The element is 18 characters long: 1 for program code, 2 for level of care, 1 for scope, 1 for coverage, 1 for foster care status, 1 for BMP status, 1 for pharmacy restriction status, 1 for MAGI indicator, 1 for “parent” flag for HMP population and 8 for redetermination date. Foster care status, BMP status, pharmacy restriction status are “Y” if the enrollee is placed in foster care, BMP, and/or pharmacy restriction, respectively. Status is “N” if the enrollee is not placed in foster care, BMP, and/or pharmacy restriction, respectively. “Parent” flag is Y for the HMP population if the individual meets the criteria for the “parent” payment under the HMP rate structure; N if the individual does not meet criteria. MAGI category is a single alpha digit (see Appendix D). The element components will be populated when available and filled with <space(s)> when not available. When other insurance information for a member is in the MDCH Third Party Liability database, the information will be transmitted in the HIPAAmandated 834 transaction in the 2320 Coordination of Benefits (COB) loop. It is the responsibility of the health plan to verify the information in the COB loop. Loop – Coordination of Benefits 2320 COB 2320 COB COB01 2320 COB COB02 Michigan Department of Community Health http://www.michigan.gov/mdch Segment – Coordination of Benefits Payer Responsibility Sequence Number Code Reference Identification “U” (Unknown) Note: Medicaid is always the payer of last resort. <Group Number> Page 15 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID 2320 Segment ID COB Data Element ID COB03 2320 REF 2320 REF REF01 2320 2320 REF REF REF02 REF01 2320 2320 REF REF REF02 REF01 2320 2320 REF DTP REF02 2320 2320 2320 2320 2330 DTP DTP DTP DTP DTP01 DTP03 DTP01 DTP03 2330 NM1 2330 2330 NM1 NM1 NM101 NM103 2330 2330 NM1 NM1 NM108 NM109 Michigan Department of Community Health http://www.michigan.gov/mdch Loop/Segment/Element Name Coordination of Benefits Code Segment – Additional Coordination of Benefits Identifiers Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Reference Identification Qualifier Reference Identification Segment – Coordination of Benefits Eligibility Dates Date/Time Qualifier Date Time Period Date/Time Qualifier Date Time Period Loop – Coordination of Benefits Related Entity Segment – Coordination of Benefits Related Entity Entity Identifier Code Name Last or Organization Name Identification Code Qualifier Identification Code Companion Guide Rules “1” (Coordination of Benefits) “ZZ” (employee identification number) <Policy Number> “6P” (Group Number) <Payer ID> “60” (Account Suffix Code) <coverage type (health scope code)> Segment is repeated twice. “344” (COB begin) <COB begin date> “345” (COB end) <COB end date> “IN” (Insurer) <Payer (Carrier) Name> “FI” (Federal Tax ID Number) <Federal Tax ID Number of Payer>, when available Page 16 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Loop ID Data Element ID 2330 Segment ID N3 2330 2330 2330 N3 N3 N4 N301 N302 2330 2330 2330 2330 N4 N4 N4 PER N401 N402 N403 2330 PER PER04 SE SE SE01 SE SE02 Michigan Department of Community Health http://www.michigan.gov/mdch Loop/Segment/Element Name Segment – Coordination of Benefits Related Entity Address Address Information Address Information Segment – Coordination of Benefits Other Insurance Company City, State, Zip Code City Name State or Province Code Postal Code Segment – Administrative Communications Contact Communication Number Loop – Transaction Set Trailer Segment – Transaction Set Trailer Number of Included Segments Transaction Set Control Number Companion Guide Rules <Payer Address Line 1> <Payer Address Line 2> <Payer (Carrier) City Name> <Payer (Carrier) two-digit State Abbreviation> <Postal (Carrier) Code> <Payer (Carrier) telephone number>, when available < total number of segments included in a transaction set> including ST and SE segments <transaction set control number> MDCH will transmit identical transaction set control numbers in ST02 and SE02. Page 17 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Supplementary Information Appendix A: Crosswalk for Maintenance Reason Code (2000 INS04) Reason Code on Transaction Proprietary Value (Reason) Administrative Error Newborn Enrollment Newborn/MA HMO Enrollment Death Admission to State Psychiatric Facility AIS Home [Resident Als prior to 10-1-98] CCI or Other Placements, Foster Care, Court Wards, Detention Centers Duplicate Recipient Ids Enrolled in Hospice Enrollment Problems Excluded Scpe of Cvrge or Prgrm Cde Hab E & D Waiver Health Plan Changes Hearing on Medical Exception or Special Disenrollment Incarceration Level of Care Changes Long Term Care MA to GA, PACE, and Spend-down No Medicaid Eligibility One Plan County Other Insurance 89 Other Insurance 90 or above PCP Availability Michigan Department of Community Health http://www.michigan.gov/mdch HIPAA 834 Transaction Maintenance Reason Code (2000 INS04) HIPAA Code Description of HIPAA 2000 INS04 Code Al No Reason Given 02 Birth 02 Birth 03 Death 07 Termination of Benefits 07 Termination of Benefits 07 Termination of Benefits 07 07 07 07 07 07 07 07 07 07 07 07 07 07 07 07 Page 18 Termination of Benefits Termination of benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Termination of Benefits Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Reason Code on Transaction Pregnant TBI [Traumatic Brain Injury] Native American Special Disenrollments CSHCS Disenrollments Enrollment into MA-MC from CSHCS-MC, MME-MC or HKHMP-MC Demographic or other change Medical Exception [member has some coverage] Initial Enrollment Overlapping enrollment segments Change in QHP Service Area Enrolled in Hospice Out of Service Area Michigan Department of Community Health http://www.michigan.gov/mdch HIPAA 834 Transaction Maintenance Reason Code (2000 INS04) 07 Termination of Benefits 07 Termination of Benefits 14 Voluntary Withdrawal 18 Suspended 22 Plan Change 22 Plan Change 25 26 28 41 43 43 Page 19 Change in identifying data elements Declined coverage Initial Enrollment Re-enrollment Change of Location Change of Location Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Appendix B: Crosswalk for Medicare Plan Code (2000 INS06-1) State of Michigan Family Independence Agency Reference Codes Manual 1-1-2000 Proprietary Description – Medicare Other Insurance (OI) Code Code 90 Recipient qualifies for or in enrolled in Medicare Part B 91 Recipient qualifies for or is enrolled in Medicare Parts A and B. 92 Recipient qualifies for or is enrolled in Medicare Part B only and has Blue Cross/Blue Shield. 93 Recipient qualifies for or is enrolled in Medicare Part B only and has other medical insurance. 94 95 96 Recipient qualifies for or is enrolled in Medicare Parts A and B and has Blue Cross/Blue Shield Recipient qualifies for or is enrolled in Medicare Parts A and B and has other medical insurance Medicare HMO (to be identified and coded by Revenue and Reimbursement Division Staff Only. Michigan Department of Community Health http://www.michigan.gov/mdch HIPAA 834 Transaction Maintenance Reason Code (2000 INS06-1) HIPAA Code Description of HIPAA 2000 INS06 Code B Medicare Part B C Medicare Part A and B B Medicare Part B B Medicare Part B C Medicare Part A and B C Medicare Part A and B C Medicare Part A and B Page 20 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05-1) MDCH Data Warehouse and DHS Program Reference Manual Proprietary Description Code 1 Non-Migrant White, not of Hispanic Origin 2 Non-Migrant Black, not of Hispanic Origin 3 Non-Migrant American Indian or Alaskan Native 4 Asian Non-Migrant 5 Non-Migrant Unknown 6 Hispanic 7 Not provided. Default value if race code is null. A Migrant White, not of Hispanic Origin B Migrant Black, not of Hispanic Origin C Migrant American Indian or Alaskan Native D Asian Migrant Migrant Unknown (few, if any, persons should E have this code) Native Hawaiian and Pacific Islander Non8 Migrant Migrant Hispanic (includes Mexican, Puerto F Rican, Cuban, Central or South American or other whites with Spanish surnames) P Native Hawaiian and Pacific Islander Migrant Michigan Department of Community Health http://www.michigan.gov/mdch HIPAA 834 Transaction Race or Ethnicity Code (2100A DMG05-1) HIPAA Code Description of HIPAA 2100 DMG05-1 Codes O N I A 7 H 7 O N I A White (Non-Hispanic) Black (Non-Hispanic) American Indian or Alaskan Native Asian or Pacific Islander Not provided. Default value if race code is null. Hispanic Not provided. Default value if race code is null. White (Non-Hispanic) Black (Non-Hispanic) American Indian or Alaskan Native Asian or Pacific Islander 7 Not provided. Default value if race code is null. P Pacific Islander H Hispanic P Pacific Islander Page 21 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 APPENDIX D – MAGI CATEGORY INDICATOR MAGI Program MAGI Categories MAGI-U19 Children under age nineteen MAGI-PW Pregnant Women MAGI-PCR Parents/Caretakers MAGI-IND Adults CHAMPS MAGI Category Indicator Values A F B G C H FPL % Test* Old New Old New Old New I Adult New D R 19-20 YR Old Disabled Institutionalized Old Disabled Non-institutionalized Old PCR Old Q P E Old J New MAGI-FFC Former Foster Care L N/A MAGI-PlanFirst Plan First M N/A *Note: Old vs New indicates if the Medicaid category was determined under the old (current) FPL% test or the new (MAGI) FPL% test. MAGI-MIChild Michigan Department of Community Health http://www.michigan.gov/mdch CHIP (MIChild) Page 22 Version Date: April 7, 2015 Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834 Benefit Enrollment and Maintenance for MHP Effective April 25, 2014 Revision Log Version Date February 1, 2011 (Draft) Effective Date January 1, 2012 February 17, 2011 (Draft) January 1, 2012 November 30, 2011 January 1, 2012 April 1, 2012 April 1, 2012 March 4, 2014 March 28, 2014 April 7, 2015 April 26, 2015 Michigan Department of Community Health http://www.michigan.gov/mdch Revision Description This document replaces Data Clarifications For The 834 Benefit Enrollment And Maintenance, Version 4010 Medicaid Health Plans, County Health Plans, and Program of All-inclusive Care for the Elderly (MHPs, CHPs and PACE), dated July 11, 2009 Corrects ISA ISA01 Authorization Information Qualifier; value sent is always “00”, *(No Authorization Information Present) Corrects element name for ISA ISA12 to Interchange Control Version Number This document includes changes identified as part of business to business testing and reflects the 5010 implementation effective January 1, 2012. Updated location and link for Electronic Submitter’s Guide. Updated Loop 2100A Segment LUI Data Element LUI02. Replaced content of Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05-1). This document updates the client reporting category to include pharmacy restriction status and BMP status. This documents updates needed for Medicaid Healthy Michigan Plan enrollment changes – FPL%, income, group compensation, and addition of Appendix D. This documents updates needed for the new MHP Daily 834 file 5790 and removal of files 2012 and 2013. Page 23 Version Date: April 7, 2015