Michigan Department of Community Health HIPAA 5010 EDI Companion Guide for

Michigan Department of
Community Health
HIPAA 5010 EDI Companion Guide for
ANSI ASC X12N 834
Benefit Enrollment and Maintenance
Medicaid Health Plans, County Health Plans, and Program of All-inclusive Care for the
Elderly (MHPs, CHPs and PACE)
Version Date November 30, 2011
Effective January 1, 2012
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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 .......................................................................................................................................................... 17
Appendix A: Crosswalk for Maintenance Reason Code (2000 INS04) ...................................................................................... 17
Appendix B: Crosswalk for Medicare Plan Code (2000 INS06-1) .............................................................................................. 19
Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05-1) ..................................................................................... 20
Revision Log ................................................................................................................................................................................ 21
Michigan Department of Community Health
http://www.michigan.gov/mdch
Page i
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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 March 2011. 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/Electronic_Submissions_Manual_030106_267252_7.pdf.
Michigan Department of Community Health
http://www.michigan.gov/mdch
Page 1
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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)
Michigan Department of Community Health
http://www.michigan.gov/mdch
Page 2
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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
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, 5013, or 5012); <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 # 5012 or 5013, “2” (Change,
Update)
If BGN = “00” and file # 4976, “4” (Verify)
If BGN=“15”, “RX”
Page 7
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Loop ID
Segment
ID
DTP
Data Element
ID
DTP
DTP01
Loop/Segment/Element
Name
Segment – File Effective
Date
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 # 5012 and 5013)
Files # 4976 and 5012 = first day of report month; file #
5013 = 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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
2000
Segment
ID
INS
Data Element
ID
INS03
Loop/Segment/Element
Name
Maintenance Type Code
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
2000
REF
2000
REF
REF01
2000
2000
REF
REF
REF02
Loop ID
Michigan Department of Community Health
http://www.michigan.gov/mdch
Segment – Member
Supplemental Identifier
Reference Identification
Qualifier
Reference Identification
Segment – Member
Supplemental Identifier
Companion Guide Rules
“030” (audit or compare; file # 4976)
“024” (cancellation or termination; files #5012 and 5013)
“021” (addition; file # 5013)
“XN” (notification only; file # 4976)
“07” (termination of benefits; file # 5012)
File # 5013 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
“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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
2000
Segment
ID
REF
Data Element
ID
REF01
2000
REF
REF02
Loop/Segment/Element
Name
Reference Identification
Qualifier
Reference Identification
2000
DTP
2000
DTP
DTP01
Segment – Member Level
Dates
Date/Time Qualifier
2000
2000
2000
2100A
2100A
2100A
2100A
2100A
DTP
DTP
DTP
DTP03
DTP01
DTP03
NM1
NM1
NM1
NM1
NM101
NM102
NM103
2100A
NM1
NM104
2100A
2100A
2100A
2100A
2100A
NM1
NM1
NM1
NM1
PER
NM105
NM107
NM108
NM109
2100A
PER
PER01
Loop ID
Michigan Department of Community Health
http://www.michigan.gov/mdch
Companion Guide Rules
“6O” (Cross Reference Number) when applicable on file
#5013
<mother’s beneficiary ID> for newborns, when applicable
on file # 5013
Date Time Period
Date/Time Qualifier
Date Time Period
Loop – Member Name
Segment – Member Name
Entity Identifier Code
Entity Type Qualifier
Name Last or Organization
Name
Name First
Name Middle
Name Suffix
Identification Code Qualifier
Identification Code
Segment – Member
Communications Numbers
Contact Function Code
“356” (eligibility begin) for new enrollment
Note: Termination of coverage will be communicated in
the 2300 DTP loop.
<enrollment begin date>
“474” (Medicaid end)
<last day of the current month>
“IL” (Insured or Subscriber)
“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>
“IP” (Insured Party)
Page 10
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
2100A
Segment
ID
PER
Data Element
ID
PER03
2100A
PER
PER04
Loop/Segment/Element
Name
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
LUI
2100A
2100A
LUI
LUI
LUI01
LUI02
Segment – Member
Language
Identification Code Qualifier
Identification Code
2100A
LUI
LUI04
Use of Language Indicator
Loop ID
Michigan Department of Community Health
http://www.michigan.gov/mdch
Companion Guide Rules
“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
“LE” (ISO 639 Language Codes)
MDCH will use the ISO 639-1 version of the ISO 639 language
codes.
“7” (Language Speaking)
Page 11
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Loop ID
Segment
ID
Data Element
ID
2100G
Loop/Segment/Element
Name
Loop – Responsible
Person
Segment – Responsible
Person
Entity Identifier Code
2100G
NM1
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
2300
2300
HD
2300
HD
HD01
Loop – Health Coverage
Segment – Health
Coverage
Maintenance Type Code
Michigan Department of Community Health
http://www.michigan.gov/mdch
Companion Guide Rules
Name Last or Organization
Name
Name First
Name Middle
Name Suffix
Segment – Responsible
Person Communications
Numbers
Communication Number
Qualifier
Communication Number
“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; file#5013)
“024” (cancellation or termination; files#5012 and 5013)
Page 12
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
2300
Segment
ID
HD
Data Element
ID
HD03
Loop/Segment/Element
Name
Insurance Line Code
2300
HD
HD04
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
Loop ID
REF01
Michigan Department of Community Health
http://www.michigan.gov/mdch
Companion Guide Rules
“HMO” (health maintenance organization) for MHP
“HTL” (includes both hospital and professional coverage)
for CHP
“LTC” (long term care) for PACE
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 13
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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, redetermination date in CCYYMMDD format>. The
element is 16 characters long: 1 for program code, 2 for level of
care, 1 for scope, 1 for coverage, 1 for foster care status, and 8
for redetermination date.
Foster care status is “Y” if the enrollee is placed in foster care
and “N” if the enrollee is not placed in foster care.
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
2320
COB
COB
COB02
COB03
2320
REF
2320
REF
REF01
2320
REF
REF02
Michigan Department of Community Health
http://www.michigan.gov/mdch
Segment – Coordination of
Benefits
Payer Responsibility
Sequence Number Code
Reference Identification
Coordination of Benefits
Code
Segment – Additional
Coordination of Benefits
Identifiers
Reference Identification
Qualifier
Reference Identification
“U” (Unknown)
Note: Medicaid is always the payer of last resort.
<Group Number>
“1” (Coordination of Benefits)
“ZZ” (employee identification number)
<Policy Number>
Page 14
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
2320
Segment
ID
REF
Data Element
ID
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
2330
NM1
NM1
N3
NM108
NM109
2330
2330
N3
N3
N301
N302
Loop ID
Michigan Department of Community Health
http://www.michigan.gov/mdch
Loop/Segment/Element
Name
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
Segment – Coordination of
Benefits Related Entity
Address
Address Information
Address Information
Companion Guide Rules
“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
<Payer Address Line 1>
<Payer Address Line 2>
Page 15
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Data Element
ID
2330
Segment
ID
N4
2330
2330
2330
2330
N4
N4
N4
PER
N401
N402
N403
2330
PER
PER04
Loop ID
SE
SE
SE01
SE
SE02
Michigan Department of Community Health
http://www.michigan.gov/mdch
Loop/Segment/Element
Name
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 (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 16
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Supplementary Information
Appendix A: Crosswalk for Maintenance Reason Code (2000 INS04)
Reason Code on Weekly 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 17
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: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Reason Code on Weekly Transaction
Pregnant
TBI [Traumatic Brain Injury]
Native American
Special Disenrollments
CSHCS Disenrollments
Medical Exception [member has some coverage]
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
26
Declined coverage
43
Change of Location
43
Change of Location
Page 18
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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 19
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
Appendix C: Crosswalk for Race or Ethnicity Code (2100A DMG05-1)
MDCH Data Warehouse and DHS Program Reference
Manual
Proprietary
Code
1
2
3
4
5
6
7
A
B
C
D
E
8
F
P
Description
Non-Migrant White, not of Hispanic Origin
Non-Migrant Black, not of Hispanic Origin
Non-Migrant American Indian or Alaskan Native
Asian Non-Migrant
Non-Migrant Unknown
Hispanic
Not provided. Default value if race code is null.
Migrant White, not of Hispanic Origin
Migrant Black, not of Hispanic Origin
Migrant American Indian or Alaskan Native
Asian Migrant
Migrant Unknown (few, if any, persons should
have this code)
Native Hawaiian and Pacific Islander NonMigrant
Migrant Hispanic (includes Mexican, Puerto
Rican, Cuban, Central or South American or
other whites with Spanish surnames)
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 20
Version Date: November 30, 2011
Michigan Department of Community Health
HIPAA 5010 EDI Companion Guide for ANSI ASC X12N 834
Benefit Enrollment and Maintenance for MHP, CHP, and PACE
Effective January 1, 2012
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
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).
Page 21
Version Date: November 30, 2011