834 benefit enrollment and maintenance 5010 companion guide · ref member supplemental identifier...
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834 Benefit Enrollment and Maintenance 5010
Companion Guide
HIPAA/V5010220A1/834
Version 1.3
Company: Blue Cross of Idaho Created 5/29/2013
Updated 1/21/2016
An Independent Licensee of the Blue Cross and Blue Shield Association
2
Table of Contents Introduction ........................................................................................................................................................................3
Enrollment .........................................................................................................................................................................3
EDI File ..........................................................................................................................................................................4
Notations and Conventions in This Guide ........................................................................................................................4
ISA Interchange Control Header ..............................................................................................................................5
GS Functional Group Header ..................................................................................................................................5 ST Transaction Set Heade r......................................................................................................................................6
BGN Beginning Segment.............................................................................................................................................6
REF Transaction Set Policy Number .........................................................................................................................7
DTP File Effective Date ..............................................................................................................................................7
Q TY Transaction Set Control Total ...........................................................................................................................7
1000A N1 Sponsor Name ....................................................................................................................................................8
1000B Loop Payer N1 Payer ..................................................................................................................................................................8
1000C Loop TPA/Broker Name N1 TPA/Broker Name .............................................................................................................................................9
1100C Loop TPA/Broker Account Information ACT TPA/Broker Account Information .....................................................................................................................9
2000 Loop Member Level Detail INS Member Level Detail........................................................................................................................................10
REF Subscriber Identifier ........................................................................................................................................11
REF Member Policy Number ...................................................................................................................................11
REF Member Supplemental Identifier.....................................................................................................................11
DTP Member Level Dates ........................................................................................................................................12
2100A Loop Member Name NM1 Member Name..................................................................................................................................................13
PER Member Communications Numbers ................................................................................................................13
N3 Member Residence Street Address ..................................................................................................................14
N4 Member City, State, ZIP Code.........................................................................................................................14
DMG Member Demographics ....................................................................................................................................14
2300 Loop Health Coverage HD Health Coverage...............................................................................................................................................16
DTP Health Coverage Dates.....................................................................................................................................17
REF Health Coverage Policy Number......................................................................................................................17
AMT Health Coverage Policy ....................................................................................................................................18
2310 Loop Provider Information LX Provider Information .......................................................................................................................................19
NM1 Provider Name .................................................................................................................................................19
N3 Provider Address .............................................................................................................................................20
N4 Provider City, State , Zip Code .........................................................................................................................20
PER Provider Communications Numbers................................................................................................................20
PLA Provider Change Reason..................................................................................................................................21
2500 Loop Flexible Spending Account FSA Flexible Spending Account...............................................................................................................................22
AMT Monetary Amount Information .......................................................................................................................23
DTP Date or Time or Period ....................................................................................................................................23
SE Transaction Set Trailer ....................................................................................................................................24 GE Functional Group Trailer ................................................................................................................................24
IEA Interchange Control Trailer ............................................................................................................................24
3
1 Introduction
1.1 Disclaimer Blue Cross of Idaho (BCI) created this Companion Guide for 834 Benefit Enrollment and
Maintenance, to use in conjunction with the 5010A1 version of the ANSI X12 Implementation Guide. This document is not a replacement for the ANSI X12 Implementation Guide, but as an additional source of information created to assist employers and business partners of Blue Cross of Idaho. The Implementation Guide is available from the Washington Publishing Company
website at http://www.wpc-edi.com/
1.2 Document Purpose The purpose of this companion guide is to describe those aspects of processing an electronic 834 Benefit Enrollment and Maintenance requests that are specific to Blue Cross of Idaho. This companion guide contains data clarifications derived from specific business rules that apply
exclusively to claims processing done by Blue Cross of Idaho. In addition, this guide includes useful information about sending and receiving data to and from Blue Cross of Idaho. Though Blue Cross of Idaho continually updates this document, the current version is always
available on the website bcidaho.com
2 Enrollment
2.1 EDI Support The Blue Cross of Idaho EDI Support Desk assists users with questions about electronic transactions. The Blue Cross of Idaho EDI Support Desk is available to all Idaho providers and vendors Monday through Friday from 8:00 a.m. to 5:00 p.m. MST at 208-331-8817 or
888-224-3341. The Blue Cross of Idaho EDI Support Desk:
Provides information on services offered
Enrolls users for claims submission and data retrieval and vendors for 27x transactions
Verifies receipt of electronic transmissions
Provides technical assistance to users who are experiencing transmission difficulties
2.2 General Business Information Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements used by Blue Cross of Idaho, but the eligibility information returned by Blue Cross of Idaho is not a guarantee of claims payment. Blue Cross of Idaho responds to all eligibility requests with the coverage information available for the patient identified, per the date provided.
4
3 EDI File
The EDI file naming convention is GroupName_elig_edi834_ccyymmdd.dat, where GroupName indicates the name of the Group whose members are shown in the file, and ccyymmdd is the file date. For test files, please use a filename that is not in this format, for example GroupName_Test_ccyymmdd.txt.
The format of the file is text, with an element separator of asterisk (*) and segment terminator of tilde (~).
4 Notations and Conventions in This Guide Under each Segment header it will say either Required or Situational. Required means the
segment must always be sent. Situational means the segment can be sent at the sender’s discretion or conditionally required by the receiver.
The “Req.” (Required) column describes whether the element is required, given the segment is present.
In cases where Date Time Period Qualifier is populated, the associated Date Time Period element must be populated, and vice versa.
5
ISA Interchange Control Header
Required
Ref # ID Name Req. Codes Notes ISA01 101 Authorization Number Y 00
ISA02 102 Code set Summary Y Should contain spaces or
zeroes (0000000000). ISA03 103 Security information
Qualifier
Y 00
ISA04 104 Security information Y Should contain spaces or zeroes (0000000000).
ISA05 105 Interchange ID Qualifier Y 30 Denotes Federal Tax ID in the following segment.
ISA06 106 Interchange Sender ID Y Federal Tax ID of the sender
ISA07 105 Interchange ID Qualifier Y 30 Denotes Federal Tax ID in the following segment.
ISA08 107 Interchange Receiver ID Y 820344294 BCI Federal Tax ID
ISA09 108 Interchange Date Y CCYYMMDD Date of the interchange ISA10 I09 Interchange Time Y HHMM Time of the interchange
ISA11 I65 Repetition Separator Y ̂ Separator used to identify
repeated data within an element
ISA12 111 Interchange Control Version Number
Y 00501 Code used to identify the version submitted
ISA13 I12 Interchange Control Number
Y Unique number identified by the sender
ISA14 I13 Acknowledgment Requested
Y 0 A code sent by the submitter requesting acknowledgement
ISA15 I14 Interchange Usage Indicator
Y P, T Code indicating Production or Test
ISA16 I15 Component Element Separator
Y > Delimiter separator
GS Functional Group Header
Required
Ref # ID Name Req. Codes Notes
GS01 479 Functional Identifier
Code
Y BE Code identifying the
application related transaction sets
6
GS02 142 Application Senders Code
Y Federal Tax ID of the Sender (Can also be another code identified by the sender)
GS03 124 Application Receivers Code
Y Code identifying receiving transmission (code must be agreed upon by sender and
receiver)
GS04 373 Group Date Y CCYYMMDD GS05 337 Group Time Y HHMMSSDD
GS06 28 Group Control Number
(must match GE02)
Y Unique Number created by
Sender GS07 455 Responsible Agency
Code
Y X Code identified by the
standard
GS08 480 Version/Release Code Y 005010X220A1
ST Transaction Set Header
Required
Ref # ID Name Req. Codes Notes
ST01 143 Transaction Set Identifier
Y 834 Code identifying Transaction Set
ST02 329 Transaction Set Control
Number
Y Unique Number that must be
unique to each transaction ST03 1705 Implementation
Convention Reference
Y 005010X220A1 Reference assigned to
Identify Implementation Convention
BGN Beginning Segment
Required
Ref # ID Name Req. Codes Notes
BGN01 353 Transaction Set Purpose Code
Y 00 00=Original
BGN02 127 Reference Identification Y 1 Reference information for a particular Transaction Set
BGN03 373 Date Y File date in format CCYYMMDD
BGN04 337 Time Y File time in format HHMM (24 hour clock)
BGN05 623 Time Code Y MT Time zone – Mountain Time
BGN06 127 Reference Identification N Not Used.
BGN07 Transaction Type Code N Not Used.
7
BGN08 306 Action Code Y 2, 4 2=Change(update), 4=Verify
REF Transaction Set Policy Number
Situational
Ref # ID Name Req. Code(s) Notes
REF01 128 Reference Identification Qualifier
38
REF02 127 Reference Identification Y Master Policy Number
DTP File Effective Date
Situational
Ref # ID Name Req. Codes Notes
DTP01 374 Date/Time Qualifier Y 007 Code indicating date or time or both
DTP02 1250 Date Time Qualifier Y D8 Code indicating date, time or date and time format CCYYMMDD
DTP03 1251 Date Time Period Y CCYYMMDD Actual date, time or range of
dates, times or dates and times.
QTY Transaction Set Control Totals
Situational
Ref # ID Name Req. Codes Notes QTY01 673 Quantity Qualifier Y DT, ET, TO Code specifying the type of
quantity. DT = Dependent Total ET = Employee Total TO = Total
QTY02 380 Quantity Y Numeric value of quantity
8
Loop 1000A
N1 Sponsor Name
Required
Ref # ID Name Req. Codes Notes
N101 98 Entity Identifier Code Y P5 Code identifying a physical location, property or individual
N102 93 Name Y Sponsor/Group name
N103 66 Code Qualifier Y FI Denotes Federal Tax ID in following element
N104 67 Identification Code Y Federal Tax ID of the Sponsor/Group
At least one of N102 or N103 is required
Loop 1000B
N1 Payer
Required
Ref # ID Name Req. Codes Notes
N101 98 Entity Identifier Code Y IN Organizational entity, physical location, property or individual
N102 93 Name Y Blue Cross of Idaho
N103 66 Identification Code
Qualifier
N FI Denotes Federal Tax ID in
following element N104 67 Identification Code N 820344294 BCI’s Federal Tax ID
If N103 or N104 is present then the other is also required.
9
Loop 1000C
N1 TPA/Broker Name
Ref # ID Name Req. Codes Notes
N101 98 Entity Identifier Code Y BO,
TV
BO=Broker or Sales Office
TV=Third Party Administrator
N102 93 Name Y TPA/Broker Name
N103 66 Code Qualifier N 94,
FI,
XV
Denotes type of identifier in
following element. 94=Code
assigned by receiver
FI=Federal Tax ID
XV=CMS Plan ID
N104 67 Identification code N Code referenced in N103
At least N102 or N103 is required.
Loop 1100C
ACT TPA/Broker Account Information
Situational
Ref # ID Name Req. Codes Notes
ACT01 508 Account Number Y TPA/Broker Account number
assigned
ACT06 508 Account Number N TPA/Broker second, optional
account number assigned
10
Loop 2000
INS Member Level Detail
Required
Ref # ID Name Req. Codes Notes
INS01 1073 Yes/No Condition Y Y, N Subscriber indicator
Y=insured is subscriber N=insured is a dependent
INS02 1069 Individual Relationship Code
Y 01,18, 19
01=Spouse, 18=Self, 19=Child (See Implementation Guide for complete list)
INS03 875 Maintenance Type Code Y 001, 021, 030
001=Change, 030=Audit or Compare (030 should always be used for full files)
INS04 1203 Maintenance Reason Code Y XN Codes to identify maintenance change entities
(see Guide for complete list)
INS05 1216 Benefit Status Code Y A Actual code identifying Status. A=Active
INS06 C052 Medicare Status Code N Blank, D, E
Identifies Medicare coverage and associated reason for Medicare Eligibility. D=Medicare, E=No Medicare
INS06-
01
1218 Medicare Plan Code N Code identifying Medicare Plan
Required when INS06 is used INS06-
02
1701 Eligibility Reason Code N Reason for Eligibility
INS07 1219 Consolidated Omnibus Budget
N Please leave blank
INS08 584 Employment Status Code Y FT, PT, RT
Code displaying employment status of claimant
INS09 1220 Student Status Code N F, N, P
Code displaying student status of a patient if 19 or older, not
handicapped and not insured INS10 1073 Condition Response code N Y/N Handicapped indicator.
Y=Handicapped, N=not handicapped
INS11 1250 Date Time Period Qualifier
N D8
INS12 1151 Date Time Period N Date of Death in format CCYYMMDD
INS13 1165 Confidentiality Code N Please leave blank
11
INS17 1470 Number N Generic Number if family members have the same birthdate (For dependents)
REF Subscriber Identifier
Required
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification Qualifier
Y 0F Reference Identification for Subscriber number
REF02 127 Reference Identification Y Social Security Number of the Subscriber
REF Member Policy Number
Required
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification Qualifier
Y 1L
REF02 127 Reference Identification Y BCI supplied 8-digit Group Number
REF Member Supplemental Identifier
Situational
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification Qualifier
N 23 23=Client Number
REF02 127 Reference Identification N Company Assigned Employee ID If REF02 is present, REF03 is required.
Required
Ref # ID Name Req. Codes Notes REF01 128 Reference Identification
Qualifier
Y DX DX=Department/Agency Number
12
REF02 127 Reference Identification Y BCI supplied Subgroup Number Required
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification
Qualifier
Y 17 17=Client Reporting Category
REF02 127 Reference Identification Y BCI supplied Class Code or
Benefit Level Code
DTP Member Level Dates
Required
Ref # ID Name Req. Codes Notes
DTP01 374 Date Time Qualifier Y 336, 337
336=Employment Begin Date 337=Employment End Date
DTP02 1250 Date Time Period Qualifier
Y D8
DTP03 1251 Date Time Period Y Date in format CCYYMMDD
Situational
Ref # ID Name Req. Codes Notes
DTP01 374 Date Time Qualifier Y 356, 357
356=Eligibility Begin Date 357=Eligibility End Date
DTP02 1250 Date Time Period Qualifier
Y D8
DTP03 1251 Date Time Period Y Date in format CCYYMMDD
13
Loop 2100A
NM1 Member Name
Required
Ref # ID Name Req. Codes Notes
NM101 98 Entity ID Y IL
NM102 1065 Entity Type Qualifier Y 1
NM103 1035 Last Name or Org Name Y Last name or Organizational Name
NM104 1036 Name, First Y First Name
NM105 1037 Name, Middle N Middle Name or Initial
NM106 1038 Name Prefix N Prefix to Name NM107 1039 Name Suffix N Suffix to Name
NM108 66 Identification Code
Qualifier
N 34 Denotes NM109 is a Social
Security Number, required if NM109 is populated.
NM109 67 Identification Code N Social Security Number. Numeric characters only.
PER Member Communications Numbers
Situational
Ref # ID Name Req. Codes Notes
PER01 366 Contact Function Code Y IP IP=Insured Party
PER03 365 Communication Number Qualifier
N HP, TE
TE=Telephone, HP= Home Phone
PER04 364 Communication Number N Actual phone number if PER03 is populated. Only numeric characters.
PER05 365 Communication Number Qualifier
N EM EM=Email
PER06 364 Communication Number N Email address if PER05 is
populated PER07 365 Communication Number
Qualifier
N Please leave blank
PER08 364 Communication Number N Please leave blank If either PER03 or PER04 is present then the other is required.
If either PER05 or PER06 is present then the other is required.
14
N3 Member Residence Street Address
Situational
Ref # ID Name Req. Codes Notes N301 166 Address Information Y Address Line 1
N302 166 Address Information N Address Line 2
N4 Member City, State, and Zip Code
Required
Ref # ID Name Req. Codes Notes N401 19 City Name Y City name (free form)
N402 156 State or Providence Code Y State
N403 1126 Postal Code Y Postal Code
N404 26 Country Code N Country Code
N405 309 Location Qualifier N Please leave Blank
N406 310 Location Identifier N Please leave Blank
N407 1715 Country Subdivision Code N Please leave Blank
DMG Member Demographics
Situational
Ref # ID Name Req. Codes Notes DMG01 1250 Date and Time period
Format Qualifier
Y D8
DMG02 1251 Date Time Period Y Date of Birth in format CCYYMMDD
DMG03 1068 Gender Code Y F,M Female, Male
DMG04 1067 Marital Status N I, M, B
I=Single, M=Married, B=Registered Domestic Partner See Guide for additional codes.
DMG05 C056 Composite Race or Ethnicity Information
N Please leave blank
DMG05-01
1109 Race or Ethnicity Code N 7, 8, A, B,
C, D,
7=Not Provided, 8=Not applicable, A=Asian or Pacific
Islander, B= Black,
15
E, F, G, H, I, J, N, O, P,
Z
C=Caucasian, D=Subcontinent Asian American, E=Other Race, F=Asian Pacific America, g=Native American, H=Hispanic,
N=Black (Non Hispanic), O=White (Non Hispanic), P=Pacific Islander, Z=Mutually defined
DMG05-02
1270 Code List Qualifier Code N RET Classification of Race or Ethnicity
DMG05-
03
1271 Industry Code N Please leave blank
DMG06 1066 Citizen Status code N Please leave blank
DMG10 1270 Code List Qualifier code N Please leave blank
DMG11 1271 Industry Code N Code from a specific industry code list
If DMG11 is present then DMG05 is required.
16
Loop 2300
HD Health Coverage
Required (at least one)
Ref # ID Name Req. Codes Notes
HD01 875 Maintenance Type Code Y 001, 021, 024, 030
001=Change, 021=Addition, 024=Cancellation or Termination, 030=Audit or Compare
HD03 1205 Insurance Line code Y MM
HLT EPO PPO HMO
DEN PDG POS VIS
MM=Major Medical
HLT=Health EPO=Exclusive Provider Org. PPO=Preferred Provider Org. HMO=Health Maintenance Org.
DEN=Dental PDG=Prescription Drug POS=Point of Service VIS=Vision
HD04 1204 Plan Coverage
Description
Y Plan Code
HD05 1207 Coverage Level Code Y CHD, DEP, E1D, E2D, E3D, E5D, E6D,
E7D, E8D, E9D, ECH,EMP, ESP,
FAM, IND, SPC, SPO, TWO
CHD=Children Only, DEP=Dependents Only, E1D=Employee and One dependent, E2D=Employee and Two
dependents, E3D=Employee and Three dependents, E5D=Employee and One or More Dependents, E6D=Employee and Two or More
Dependents, E7D=Employee and Three or More Dependents, E8D=Employee and Four or More Dependents, E9D=Employee and
Five or more Dependents, ECH=Employee and Children EMP=Employee Only ESP=Employee and Spouse,
FAM=Family, IND=Individual, SPC=Spouse and Children, SPO=Spouse Only, TWO=Two Party
17
DTP Benefit Coverage Dates
Required
Ref # ID Name Req. Codes Notes DTP01 374 Date Time Qualifier Y 303,
348, 349
303=Maintenance Effective,
348=Benefit Begin Date 349=Benefit End Date
DTP02 1250 Date Time Period Qualifier
Y D8
DTP03 1251 Date Time Period Y Date in format CCYYMMDD
REF Health Coverage Policy Number
Situational
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification Qualifier
Y 1L
REF02 127 Reference Identification Y Group or Policy Number. May contain 12345678 if Group or Policy number is not available
REF Health Coverage Policy Number
Situational
Ref # ID Name Req. Codes Notes
REF01 128 Reference Identification Qualifier
Y 17
REF02 127 Reference Identification Y Attestation Indicator
Possible Values: 0=Do not send claims and do not send eligibility
1=Send claims only 2=Send eligibility only 3=Send claims and eligibility
18
AMT – Health Coverage Policy
Situational
Ref # ID Name Req. Codes Notes AMT01 522 Amount Qualifier Code Y B9
C1 D2 EBA
FK P3 R
B9=Co-insurance-Actual
C1=Co-Payment Amount D2=Deductible Amount EBA=Expected Expenditure Amount
FK=Other Unlisted Amount P3=Premium Amount R=Spend Down
AMT02 782 Monetary Amount Y
19
Loop 2310
LX Provider Information
Situational
Ref # ID Name Req. Codes Notes
LX01 554 Assigned Number Y 1 Number assigned to separate within transaction sets. Should contain “1”
NM1 Provider Name
Situational
Ref # ID Name Req. Codes Notes
NM101 98 Entity Identifier Code Y P3 P3=Primary Care Physician
NM102 1065 Entity Type Qualifier Y 1, 2 1=Person, 2=Non-Person Entity
NM103 1035 Name Last or
Organization
Y Name of Primary Care
Physician NM104 1036 Name First N
NM105 1037 Name Middle N
NM106 1038 Name Prefix N
NM107 1039 Name Suffix N
NM108 66 Identification Code Qualifier
Y 34,FI,SV,XX 34=SSN, FI=Federal Tax ID, SV=Service Provider Num, XX=CMS NPI
NM109 67 Identification Code Y Provider ID
NM110 706 Entity Relationship Code
Y 25,26, 72 25=Established Patient 26=Not Established Patient
72=Unknown
20
N3 Provider Address
Situational
Ref # ID Name Req. Codes Notes N301 166 Address Information Y Provider Address
N302 166 Entity Type Qualifier N
N4 Provider City, State, Zip Code
Situational
Ref # ID Name Req. Codes Notes
N401 19 City Name Y
N402 156 State or Province Y
N403 116 Postal Code Y
N404 26 Country Code N
PER Provider Communications Numbers
Situational
Ref # ID Name Req. Codes Notes
PER01 366 Contact Function Code Y IC Information Contact PER02 93 Not Used N
PER03 365 Communication
Number Qualifier
Y HP, TE, WP HP-Home Phone Number
TE-Telephone WP-Work Phone Number
21
PLA – Provider Change Reason
Situational
Ref # ID Name Req. Codes Notes PLA01 306 Action Code Y 2 Change
PLA02 98 Entity Identifier Code Y 1P Provider
PLA03 373 Date Y Provider Effective Date in format CCYYMMDD
PLA04 337 Time N Time
PLA05 1203 Maintenance Reason Code
N 14, 22, 46, AA, AB,
AC, AD, AE, AF, AG, AH, AI, AJ
14 Voluntary Withdrawal 22 Plan Change
46 Current Customer Information File in Error AA Dissatisfaction with Office Staff
AB Dissatisfaction with Medical Care AC Inconvenient Office
Location
AD Dissatisfaction with Office Hours AE Unable to Schedule Appointments in a Timely
Manner AF Dissatisfaction with Physician’s Referral Policy AG Less Respect and
Attention Time Given than to Other Patients AH Patient Moved to a New Location
AI No Reason Given AJ Appointment Times not Met in a Timely Manner
22
Loop 2500
FSA Flexible Spending Account
Situational
Ref # ID Name Req. Codes Notes
FSA01 875 Maintenance Type Code Y 001, 021,024, 030
001=Change, 021=Addition, 024=Cancellation or Termination, 030=Audit or
Compare
FSA02 1202 Flexible Spending Account Selection Code
Y D, H D=Dependent Care, H=Healthcare
FSA03 1203 Reason Code Y 36 36=Contribution or Plan Allocation
FSA04 508 Account Number N Account number assigned
FSA05 594 Frequency Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, B, C, H, Q, X,
U, Z
1=Weekly, 2=Biweekly, 3=Semimonthly, 4=Monthly, 5=Other, 6=Daily, 7=Annual, 8=Two Calendar Months,
9=Lump-Sum Separation Allowance, B=Year to Date, C=Single, H=Hourly, Q=Quarterly, S=Semiannual,
U=Unknown, Z=Mutually Defined
FSA06 1204 Plan Coverage Description N Plan or coverage description
FSA07 1161 Product Option Code N 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, N,
O, S, 10, 11, 12, 13, 14, 15, 28,
29
1=Pretax, 2=Post tax, 3=Qualified, 4=Non Qualified, 5=401K, 6=Individual Retirement Account, 7=Keogh,
8=Simplified Employee Pension, 9=Single Premium, A=First to Die, B=Last to Die, C=Child Rider, D=discontinue
one Bill Submission, N=Benefit Continuation, O=One bill Submission, S=Salary Continuation, 10=Flexible
premium, 11=Variable Premium, 12=Fixed Premium, 13=Registered under the Income Tax Act of Canada,
14=Non Registered und the Income Tax Act of Canada,
23
15=registered Spousal case, 28=Exclusive, 29=Shopped
FSA08 1161 Product Option Code N Not Required
FSA09 1161 Product Option Code N Not Required
FSA04 is the flexible spending account policy number.
FSA05 specifies the frequency of contribution.
AMT Monetary Amount Information
Situational
Ref # ID Name Req. Codes Notes
AMT01 522 Amount Qualifier Code Y 1 Code to qualify amount
AMT02 782 Monetary Amount Y Actual Monetary Amount
AMT03 478 Credit/Debit Flag Code N C, D Code indicating if it is a credit or debit
DTP Date or Time or Period – Payroll Dates
Situational
Ref # ID Name Req. Codes Notes
DTP01 374 Date/Time Qualifier N 390, 391
390=Payroll Begin Date 391=Payroll End Date
DTP02 1250 Date Time Period Format Qualifier
N D8
DTP03 1251 Date Time Period N Date in format CCYYMMDD
24
SE Transaction Set Trailer
Required
Ref # ID Name Req. Codes Notes SE01 96 Number of Included
Segments
Y Total number of Segments
included in the transaction set including ST and SE segments
SE02 329 Transaction Set Control Number
Y Control number that must be unique within the transaction set functional group, assigned by the
Originator. Must match element ST02.
GE Functional Group Trailer
Required
Ref # ID Name Req. Codes Notes
GE01 97 Number of Transaction
Sets Included
Y Total number of transaction sets
included in the functional group or interchange
GE02 28 Group Control Number Y Assigned number originated and maintained by the sender. Must match element GS06.
IEA Interchange Control Trailer
Required
Ref # ID Name Req. Codes Notes
IEA01 116 Number of Included Functional Groups
Y A count of the number of functional groups included in an interchange
IEA02 112 Interchange Control Number
Y A control number assigned by the Interchange sender. Must match
ISA13.
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