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834 Submission Section - PM

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Set the 834 Benefit Enrollment Submission file default values.

Prerequisites:

  • The Enable 834 Submissions registry setting must be set to 'Y'.

Interchange Control Header (ISA)

  1. In the Authorization Information Qualifier (ISA-01) field, choose the additional information category/type.

  2. In the Authorization Information (ISA-02) field, type the authorization information value.

  3. In the Security Information Qualifier (ISA-03) field, select the type of security information requested. The value populates the ISA-03 segment.

  4. In the Security Information (ISA-04) field, enter the security information value.

  5. In the Interchange ID Qualifier (ISA-05) field, select the interchange ID category. The value chosen here populates the ISA-05 segment.

  6. In the Interchange Sender ID (ISA-06) field, add the sender ID.

  7. In the Interchange ID Qualifier (ISA-07) field, select the value, which populates the ISA-07 segment.

  8. In the Interchange Receiver ID (ISA-08) field, type the receiver ID for the interchange.

  9. In the Repetition Separator (ISA-11) field, enter the value to be used as the repetition separator.

  10. In the Acknowledgement Requested (ISA-14) field, denote whether acknowledgement will be requested from the interchange receiver. The value populates the ISA-14 segment.

  11. In the Usage Indicator (ISA-15) field, select the data usage.

Function Group Header (GS)

  1. In the Application Senders Code (GS-02) field, type the sender's code.

  2. In the Applications Receiver Code (GS-03) field, type the receiver's code.

  3. In the Specify Time Format in GS-05 field, select the time format to use. (HH = two-digit hours, MM = two-digit minutes, SS = two-digit seconds)

  4. In the Version Identifier Code (GS-08) field, select the applicable version for the 834 Submission filing.

Transaction Set Policy Number (REF)

  1. In the Master Policy Number (REF-02) field, enter the master policy number.

Sponsor Name (Loop 1000A)

  1. In the Plan Sponsor Name (N1-02) field, fill in the name of the plan sponsor.

  2. In the Identification Code Qualifier (N1-03) field, select the identification code type.

  3. In the Sponsor Identifier (N1-04) field, enter the sponsor identification code.

Payer (Loop 1000B)

  1. In the Insurer Name (N1-02) field, fill in the name of the insurer.

  2. In the Identification Code Qualifier (N1-03) field, select the identification code type.

  3. In the Insurer Identification Code (N1-04) field, enter the insurer identification code.

TPA/Broker Name (Loop 1000C)

  1. In the TPA/Broker Name field, fill in the TPA/broker name.

  2. In the Identification Code Qualifier (N1-03) field, select the identification code type.

  3. In the TPA/Broker Identification Code (N1-04) field, enter the TPA/broker ID code.

TPA/Broker Account Information (Loop 1100C)

  1. In the TPA/Broker Account Number (ACT-01) field, enter the number for the TPA/broker account.

Member Level Detail (Loop 2000)

  1. In the Specify Information to Include in Status Information Effective Date (2000-DTP-03) field, choose how the Member Level Dates (2000-DTP) segment within the 834 Submission will be populated, based upon the selected value(s) as follows:

  • Maintenance Date (Date Entry Date) - DTP-01 will be populated with '303', DTP-02 will be populated with 'D8', and DTP-03 will be populated with the data entry date of the financial eligibility information.

  • Eligibility Begin Date/End Date - Two DTP segments will be populated. The first DTP segment will be populated as follows: DTP-01 will be populated with '356', DTP-02 will be populated with 'D8', and DTP-03 will be populated with the Coverage Effective Date from Financial Eligibility. The second DTP segment will be populated as follows: DTP-01 will be populated with '357', DTP-02 will be populated with 'D8', and DTP-03 will be populated with Coverage Expiration Date from financial eligibility. The second DTP segment will only be populated if the coverage expiration date is defined.