A service of Maryland Health Benefit Exchange

834 Enrollment Transaction

Deep DiveMay 2, 2013

Agenda

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Version

Scheduling

Validation

Connectivity

Security

834 file format

Reconciliation

Q&A

834 Version

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Version for 10/1

– 5010220A1 standard

– Batch file processing only, no real time enrollment

transactions

– Outbound standard for Individual, SHOP,

reconciliation, CMS reporting

– Inbound standard from Carriers and TPAs utilize

same version

Inbound Scheduling

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834 files from the Maryland Health Connection

will be transmitted during the nightly batch

process

– Midnight to 5:00 am (pending production volume)

Maryland Health Connection expects

acknowledgements to be delivered within a 24

hour window

Outbound Scheduling

834 files from the Carrier and TPAs will be processed

starting at 9:00 am

Maryland Health Connection generates

acknowledgements within a 24 hour window

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Inbound and Outbound

Validation

Carrier and TPA must follow SNIP 1 and SNIP 2

edits mandated by HIPAA

Maryland Health Connection will follow the SNIP 1

and SNIP 2 edits mandated by HIPAA

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Connectivity

SFTP server where a Carrier/TPA picks up the file

Inbox

– Inbound files from Maryland Health Connection to Carrier/TPA

Outbox

– Outbound files from Carrier/TPA to Maryland Health Connection

Files are archived in corresponding archive folders for future reference and/or error resolution

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Security

Files that contain PHI must be encrypted:

– Inbound – files from the Maryland Health

Connection sent to the Carrier and TPA will be

encrypted using PGP with the respective Carrier

and TPA public key

– Outbound – files from Carrier and TPA sent to the

Maryland Health Connection will be encrypted

using PGP with the Maryland Health Connection’s

public key

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ISA – Interchange Control Header

ISA06 – Interchange Sender ID

– HIX01MD

ISA08 – Interchange Receiver ID

– Assigned to Carrier and TPA as per the Business Agreement

ISA13 – Interchange Control Number

– Unique control number for each file sent must increment from one day to the next

ISA15 – Usage Indicator

– T = Test Data

– P = Production Data

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GS – Functional Group Header

GS02 – Application Sender's Code

– Must be the same value as ISA06

GS03 – Application Receiver’s Code

– Must be the same value as ISA08

GS06 – Group Control Number

– Unique control number for each group sent must

increment from one day to the next

GS08 – Version Identifier Code

– Must be 005010X220A1

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ST – Transaction Set Header

SE – Transaction Set Trailer

Individual Market

– One individual information will be looped in one ST-

SE transaction

SHOP Market

– One group information will be looped in one ST-SE

transaction

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Loop 1000A – Sponsor Name

Individual Market

– N102 – Subscriber name or Responsible Person name

– N103 – FI

– N104 – SSN is required as the identification code

SHOP Market

– N102 – Employer group name

– N103 – 24

– N104 – Employer TIN is required as the identification code

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Loop 1000B – Payer

N102 – Carrier Name

N103 – FI

N104 – Assigned to Carrier as per the Business

Agreement (same as ISA08 & GS03)

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Loop 1000C / 1100C –

TPA/Broker/Navigator

Individual Market

– Navigator Information

– Broker Information

SHOP Market

– Navigator Information

– Broker Information

– TPA and Broker Information

N102 – Navigator or Broker Name

N103 – FI

N104 – Navigator or Broker Tax ID

ACT01 – Navigator, Broker, or TPA Account Number

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INS – Member Level Detail

INS01 – Response Code

– Y = Insured

– N = Dependent

INS03 – Maintenance Type Code

– Maryland Health Connection uses this code to

identify the specific type of maintenance001-Change

021-Addition

024-Cancellation

025-Reinstatement

030-Audit or Compare

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REF – Subscriber Identifier

REF01 – 0F (0F=Subscriber Number)

REF02 – Subscriber Number assigned by

Maryland Health Connection for identification

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Loop 2100A – Demographic

Information

NM103 – Last Name

NM104 – First Name

NM108 – 34

NM109 – SSN

N3/N4 – Address

DMG02 – Date of Birth

DMG03 – Gender Code

DMG05-1 – Race Code

HLH01 – Tobacco Usage Indicator

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HD – Health Coverage

HD01 – same as INS03

HD03 – Insurance Line Code (DEN, HLT)

– Used to identify the insurance type under coverage

HD05 – Coverage Level Code (EMP, FAM, etc.)

– Level of coverage being provided

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DTP – Health Coverage Dates

DTP01 – 303/348

– Effective date of coverage

DTP01 – 349

– Coverage termination date

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REF – Health Coverage

Policy Number

REF01 – 1L (1L = Qualifier for Policy Number or

Plan ID)

– Will transmit when the Exchange Assigned Policy

Identifier will be conveyed in the associated REF02

element.

REF02 – Policy Number or Plan ID

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Loop 2310 – Provider

Information

LX – Provider Information is sent when required

by Carrier

NM108 – Provider Identification Code Qualifier

– SV = Service Provider Number

– XX = Centers for Medicare and Medicaid Services

National Provider Number

NM109 – Provider Identification Code

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Loop 2750 – MD-Specific

Reporting Categories

N101 – Participant

N102 – Carrier to Bill/CSR AMT/APTC AMT

REF02 – CSR AMT/APTC AMT

DTP03 – Effective Date

APTC

– Amount the QHP issuer can expect to receive toward the total premium payment (APTC)

CSR

– Advance CSR payment amount

If an individual elects to pay the Carrier, this information is sent in this reporting category loop

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Reconciliation

Reconciliation files will be processed on the 15th

of each month

Refer to the Carrier Integration Package, Section

10.5 for a list of required reconciliation data

elements

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QUESTIONS?

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