Benefit Enrollment and Maintenance (834)



MAXIMUSBenefit Enrollment and Maintenance (834)Louisiana Medicaid EDI Transaction SetCompanion GuideOriginal Publication: 12/13/2011Latest Update: 05/05/2014Version 2.3This guide to be used in conjunction with the X12N/005010X220A1 Implementation Guide, published June 2010.2397125-4665980Revision HistoryPlease accept all changes to the previous version before creating a new version. This will allow the readers to quickly identify changes specific to each version. DateAuthorVersion08/17/2011Tina Martinez1.00 – Original 5010 Version 834 Guide, initial draft08/29/2011Tina Martinez1.01 – Modified Segment Data Requirements09/11/2011Tina Martinez1.02 – Removed SV from NM10809/20/2011Tina Martinez1.03 – Modified examples to match data sent09/21/2011Tina Martinez1.04 – Changed Time zone to CT09/22/2011Tina Martinez1.05 – Changes to GS05, BGN05, N04, ISA08, ISA14, NM1 09/22/2011Tina Martinez1.06 – Added 2300 REF segment for Parish, Added Appendix A &B09/22/2011Daryl Sharp1.07 – Minor editing changes09/26/2011Tina Martinez1.08 – Minor editing changes09/29/2011Tina Martinez1.09 – Modified Appendix A Ethnicity Codes10/20/2011Heather Babich1.10 – Changes to INS08, REF01, Added NM1 233010/21/2011Chris Diebold1.11 – Added Appendix C10/21/2011Tina Martinez2.00 – Reviewed and Minor Edits10/22/2011Tina Martinez2.01 – Added 1.9.1 changes to current document, modified 2300 REF codes10/23/2011Tina Martinez2.02 – ISA modifications10/27/2011Tina Martinez2.03 – Add 2100A LUI Segment, 2000 Ref Segment, NM110 2310 & 2100G. Minor Edits.10/31/2011Tina Martinez2.04 – 230011/02/2011Chris Diebold2.05 – Added Appendix D and Appendix E11/11/2011Tina Martinez2.06 – Modified11/18/2011Tina Martinez2.07 – Removal of COB11/21/2011Pinky Patnaik2.08 – Updates to GS02,INS08 and HD04 segments11/23/2011Pinky Patnaik2.09 – Added the Auto/Choice indicator to HD04 segment12/07/2011Anita Webb2.10 – Added sections example diagrams, REF*1L segment to 2000 Loop.12/08/2011Anita Webb2.11 – Editing changes after group review. Set Medicare elements to Not Sent.12/09/2011Anita Webb2.12 – Modified LOOP 1000A N103, changed to FI, N104, added value12/13/2011Anita Webb2.13 – Updated the values of the Federal Tax ID, LA Medicaid Policy number has tax id with “1” prefix.8/23/2012Jeff Hines2.14 - Replaced Appendix D with a current code cross reference.10/17/2012Jeff Hines2.15 – Per LA DHH suggestion, removed the word “can” from page 6, section 1.2 and added additional verbiage referencing section and page number for ST segment on page 11. Updated ? in attributes column to read “1/2” on multiple pages, added “024” as a transaction type on page 26, section 2.2.23, corrected “LaHipp” to “ LaHiPP” in Appendix D and corrected GS07 and GS08 segments to have a field type of “ID” instead of “DT”. 10/30/2012Jeff Hines2.16 - Added Appendix G to define EDI element attributesChanged INS segment example in section 2.2.8 to better reflect data sent in production files11/28/2012Jeff Hines2.17 – Change 2300 loop HD04 segment 3/8/2013Jeff Hines2.18 – Added maintenance reason code 917 to Appendix C.5/13/2013T. Martinez2.19 - Added 2700 Loop Historical Reporting6/18/2013Jeff Hines2.20 - Added mother’s ID information to 2000 loop member supplemental identifier section 2.2.11 on page 17. Added Appendix H on page 44 as a cross reference between the Recipient Header File received from Molina and where the fields are mapped in the MAXIMUS outbound 834 file. 7/16/2003Jeff Hines2.21 Added verbiage regarding loop 2700 stating that the 2700 loop referenced in sections 2.28 through 2.33 on pages 29 – 32 will only be sent in the monthly recon file and not in daily files.7/26/2013Jeff Hines2.22 – Validated the 2100A loop residential address in section 2.2.15, page 21 and the 2100C loop mailing address in section 2.2.20, page 25 are correct and in accordance with the X12 834 implementation guide.8/15/2013Jeff HinesAdded description to section 2.2.24 on page 27 that the DTP*348 coverage begin date will serve as the start date for the AC/TC reconciliation transaction. Also added note to this section that it will contain a range of coverage in the reconciliation file, not a month by month listing. Added the RX code to denote a quarterly AC/TC recon file to section 2.2.4 on page 12.5/5/2014Steve MarschallAdded2 date segments In the 2000 Loop for Member PBS begin & end dates. Segments added to section 2.2.12 on page 18.Signature PageThe following shows the understanding and agreement for the use of this document as the Louisiana EB 834 5010 Guide.<NAME><Title/Role>Date: _________________________________________________________<NAME><Title/Role>Date: _________________________________________________________<NAME><Title/Role>Date:__________________________________________________________<NAME><Title/Role>Date: ___________________________________________________________TABLE OF CONTENTS TOC \o "3-3" \h \z \t "Heading 1,1,Heading 2,2" Signature Page PAGEREF _Toc356292092 \h 31Purpose PAGEREF _Toc356292093 \h 61.1Background PAGEREF _Toc356292094 \h 61.2Usage & Special Instructions PAGEREF _Toc356292095 \h 61.3Definitions PAGEREF _Toc356292096 \h 61.4Delimiters PAGEREF _Toc356292097 \h 72Structure PAGEREF _Toc356292098 \h 72.1Transaction Set Listing PAGEREF _Toc356292099 \h 72.1.1Table 1 – Header PAGEREF _Toc356292100 \h 72.1.2Table 2 – Detail PAGEREF _Toc356292101 \h 72.2834 Segment Detail PAGEREF _Toc356292102 \h 82.2.1ISA - Interchange Control Header PAGEREF _Toc356292103 \h 82.2.2GS - Functional Group Header PAGEREF _Toc356292104 \h 102.2.3ST - Transaction Set Header PAGEREF _Toc356292105 \h 102.2.4BGN - Beginning Segment PAGEREF _Toc356292106 \h 112.2.5DTP – File Effective Date PAGEREF _Toc356292107 \h 122.2.6N1 – Sponsor Name PAGEREF _Toc356292108 \h 132.2.7N1 – Payer PAGEREF _Toc356292109 \h 132.2.8INS – Member Level Detail PAGEREF _Toc356292110 \h 142.2.9REF – Subscriber Identifier PAGEREF _Toc356292111 \h 162.2.10REF – Member Policy Number PAGEREF _Toc356292112 \h 162.2.11REF – Member Supplemental Identifier PAGEREF _Toc356292113 \h 172.2.12DTP – Member Level Dates PAGEREF _Toc356292114 \h 172.2.13NM1 – Member Name PAGEREF _Toc356292115 \h 182.2.14PER – Member Communication Numbers PAGEREF _Toc356292116 \h 192.2.15N3 – Member Residence Street Address PAGEREF _Toc356292117 \h 202.2.16N4 – Member City, State, Zip Code PAGEREF _Toc356292118 \h 212.2.17DMG – Member Demographics PAGEREF _Toc356292119 \h 212.2.18LUI – Member Language PAGEREF _Toc356292120 \h 222.2.19NM1 – Member Mailing Address PAGEREF _Toc356292121 \h 232.2.20N3 – Member Mail Street Address PAGEREF _Toc356292122 \h 242.2.21N4 – Member Mail City, State, Zip Code PAGEREF _Toc356292123 \h 242.2.22NM1 – Responsible Person PAGEREF _Toc356292124 \h 252.2.23HD – Health Coverage PAGEREF _Toc356292125 \h 262.2.24DTP – Health Coverage Dates PAGEREF _Toc356292126 \h 272.2.25REF – Health Coverage Policy Number PAGEREF _Toc356292127 \h 282.2.26LX – Provider Information PAGEREF _Toc356292128 \h 282.2.27NM1 – Provider Name PAGEREF _Toc356292129 \h 282.2.28LS – Additional Reporting Categories PAGEREF _Toc356292130 \h 302.2.29LX – Member Reporting Categories PAGEREF _Toc356292131 \h 302.2.30N1 – Reporting Category PAGEREF _Toc356292132 \h 312.2.31REF – Reporting Category Reference PAGEREF _Toc356292133 \h 312.2.32DTP – Report Category Date PAGEREF _Toc356292134 \h 322.2.33LE – Additional Reporting Categories Loop Termination PAGEREF _Toc356292135 \h 322.2.34SE – Transaction Set Trailer PAGEREF _Toc356292136 \h 332.2.35GE –Functional Group Trailer PAGEREF _Toc356292137 \h 332.2.36IEA –Interchange Control Trailer PAGEREF _Toc356292138 \h 343Testing PAGEREF _Toc356292139 \h 343.1Xchange Gateway PAGEREF _Toc356292140 \h 343.1.1Xchange Gateway Server PAGEREF _Toc356292141 \h 343.1.2Access PAGEREF _Toc356292142 \h 343.1.3User Account Activation PAGEREF _Toc356292143 \h 343.1.4Self Service Password Administration PAGEREF _Toc356292144 \h 353.1.5Connectivity Issues PAGEREF _Toc356292145 \h 353.1.6File Locations PAGEREF _Toc356292146 \h 35Appendix A – Ethnicity Codes PAGEREF _Toc356292147 \h 36Appendix B – Parish Codes PAGEREF _Toc356292148 \h 37Appendix C – Capitation codes PAGEREF _Toc356292149 \h 39Appendix D – Maintenance Reason Codes PAGEREF _Toc356292150 \h 40Appendix D – Maintenance Reason Codes – Continued PAGEREF _Toc356292151 \h 41Appendix F – Language Codes PAGEREF _Toc356292152 \h 43Appendix G – Companion Guide Attribute Definitions PAGEREF _Toc356292153 \h 44PurposeThis companion guide is to be used in implementing the ASC X12N 834 Benefit Enrollment and Maintenance Set for use with the LA Enrollment Broker Project. Trading Partner specific guidelines have been added throughout this guide to assist in use for this project’s Trading Partners; for further information please refer to the ASC X12N 834 (005010X220 and 005010X220A1) implementation guides. Note: This guide is intended only as a supplement to and NOT a replacement for the ASC X12N 834 Benefit Enrollment and Maintenance Implementation Guide as mandated under HIPAA. BackgroundOn January 16, 2009, HHS published two final rules to adopt updated HIPAA standards; these rules are available at the Federal Register. One of these rules adopted the new X12 5010 version and set the compliance date for all covered entities to January 1, 2012. For more information go to Usage & Special InstructionsEach health plan will receive two types of files, Daily and Monthly Files.Daily files are transmitted from the enrollment broker to the BAYOU Health Plan’s and contain records that have passed application system edits. These transactions include enrollment, disenrollment, or change records for the health plan.The Monthly file is the Plan’s full positive file of enrollments. This file consists of clients enrolled the CCN in the given Month. All dates are 8 character dates in the format CCYYMMDD. The only date data element that is in YYMMDD is the Interchange date data element in the ISA segment.Both the Daily and Monthly files need to be processed to ensure that all enrollment transactions are in sync with the Louisiana Medicaid records.DefinitionsThe following table includes definitions for the abbreviations and annotations in this document. ElementDefinitionCommentSegment LevelREQUIREDSegment must be transmittedSITUATIONALSegment may be transmitted if data is available and supports the business or applicationElement LevelREQUIREDData element must have valid data and be transmittedSITUATIONALData element may be transmitted if data is available. If another data element in the same segment exists and follows the current element the character used for missing data should be entered.NOT USEDData elements included in the shaded areas of the Implementation Guide are NOT USED according to the standard and no attempt should be made to include these in transmissions.GeneralUSAGEIndicates if the Segment or Element is Required, Situational or Not Used.REF DES.Reference designatorNameDescriptive name of the data element.AttributesIndicates the different attributes of the segment or element. Includes the requirement designator, data type and minimum/maximum length.Please review the ASC X12N Implementation Guide for detailed instructions regarding the above.DelimitersA delimiter is a character used to separate two data elements or components elements or it can be used to terminate a segment. Once specified in the interchange header, delimiters are not to be used in a data element value elsewhere in the interchange.The following delimiters will be used for the Louisiana Medicaid enrollment file.CharacterNameDelimiter*AsteriskData Element Separator^CaratRepetition Separator:ColonComponent Element Separator~Tilde Segment TerminatorStructureThe transmission of the data follows the Interchange control structure as outlined in the ASC X12N/005010X220 guide. Refer to the guide for the Transmission Control Schematic.Transaction Set ListingThis section lists the levels, loops, and segments contained in this companion guide. The layout of the table shows the nesting of the different loops. Detailed specifications begin in section 2.2.3 (ST – Transaction Set Header)Table 1 – HeaderSee Section 2.2.3 through 2.2.7 for detailed segment specifications.POS #Segment IDNameUsageRepeatLoop Repeat0100STTransaction Set HeaderRequired10200BGNBeginning SegmentRequired10400DPTFile Effective DateSituational>1LOOP ID – 1000A SPONSOR NAME10700N1Sponsor NameRequired1LOOP ID – 1000B PAYER10700N1PayerRequired1Table 2 – DetailSee Sections 2.2.8 through 2.2.27 for detailed segment specifications.POS #Segment IDNameUsageRepeatLoop RepeatLOOP ID – 2000 MEMBER LEVEL DETAIL>10100INSMember Level DetailRequired10200REFSubscriber IdentifierRequired10200REFMember Supplemental IdentifierSituational130200REFMember Policy NumberSituational10250DTPMember Level DatesSituational24LOOP ID – 2100A MEMBER NAME10300NM1Member NameRequired10400PERMember Communications NumbersSituational10500N3Member Residence Street AddressSituational10600N4Member City, State, ZIP CodeRequired10800DMGMember DemographicsSituational11500LUIMember LanguageSituational>1LOOP ID – 2100C MEMBER MAILING ADDRESS10300NM1Member Mailing AddressSituational10500N3Member Mail Street AddressRequired10600N4Member Mail City, State, ZIP CodeRequired1LOOP ID – 2100G RESPONSIBLE PERSON130300NM1Responsible PersonSituational1LOOP ID – 2300 HEALTH COVERAGE992600HDHealth CoverageSituational12700DTPHealth Coverage DatesRequired62900REFHealth Coverage Policy NumberSituational14LOOP ID – 2310 PROVIDER INFORMATION303100LXProvider InformationSituational13200NM1Provider NameRequired16900SETransaction Set TrailerRequired1834 Segment DetailThis section specifies the loops, segments, data elements, and codes used by the Louisiana EB project.ISA - Interchange Control HeaderX12 Segment Name: Interchange Control HeaderX12 Purpose: To start and identify an interchange of zero or more functional groups and interchange-related control segmentsSegment Repeat: 1Usage: REQUIREDExample:ISA?00?..........?00?..........?ZZ?SUBMITTERS.ID..?30?RECEIVERS.ID...?030101?1253?^?00501?000000905?0?T?:~USAGEREF.DES.Name AttributesREQUIREDISA01Authorization Information Qualifier MID2/2Code identifying the type of information in the Authorization InformationCodeDefinitionComments00No Authorization Information PresentNo Meaningful Information in I02REQUIREDISA02Authorization Information MAN10/10Not used but required. Fill with spaces.REQUIREDISA03Security Information Qualifier MID2/2Code identifying the type of information in the Security InformationCodeDefinitionComments00No Security Information PresentNo Meaningful Information in I04REQUIREDISA04Security Information MAN10/10Not used but required. Fill with spaces.REQUIREDISA05Interchange ID Qualifier MID2/2Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualifiedCodeDefinitionCommentsZZMutually DefinedREQUIREDISA06Interchange Sender ID MAN15/15The identification code for the Louisiana Medicaid for routing data is LABAYOUHEALTHREQUIREDISA07Interchange ID Qualifier MID 2/2Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualifiedCodeDefinitionComments30US Federal Tax Identification NumberREQUIREDISA08Interchange Receiver ID MAN15/15The Receivers Identification code is CCN Federal Tax IDREQUIREDISA09Interchange Date MDT6/6Date of the interchangeFORMAT:YYMMDDREQUIREDISA10Interchange Time MTM4/4Time of the interchangeFORMAT:HHMMREQUIREDISA11Repetition Separator M1/1The Repetition Separator used is ^REQUIREDISA12Interchange Control Version Number MID5/5Code specifying the version number of the interchange control segmentsCodeDefinitionComments00501Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003REQUIREDISA13Interchange Control Number MNO9/9A control number assigned by the interchange sender. This number must be identical to IEA02REQUIREDISA14Acknowledgment Requested MID1/1Code indicating sender’s request for an interchange acknowledgmentCodeDefinitionComments0No Interchange Acknowledgment RequestedREQUIREDISA15Interchange Usage Indicator MID1/1Code indicating whether data enclosed by this interchange envelope is test, production or informationCodeDefinitionCommentsPProductionTTestREQUIREDISA16Component Element Separator M1/1The Component Element Separator used is :GS - Functional Group HeaderX12 Segment Name:Functional Group HeaderX12 Purpose: To indicate the beginning of a functional group and to provide control informationSegment Repeat: 1Usage: REQUIREDExample:GS?BE?SENDER CODE?RECEIVER CODE?19991231?0802?1?X?005010X220A1~USAGEREF.DES.Name AttributesREQUIREDGS01Functional Identifier CodeMID2/2Code identifying a group of application related transaction setsCodeDefinitionCommentsBEBenefit Enrollment and Maintenance (834)REQUIREDGS02Application Sender’s CodeMAN2/15Sender's Identifications code is LABAYOUHEALTHREQUIREDGS03Application Receiver’s CodeMAN2/15Code identifying party receiving transmissionBAYOU Health Plan’s ID CodeREQUIREDGS04DateMDT8/8Function Group Creation DateFORMAT: YYMMDDREQUIREDGS05TimeMTM4/8Creation TimeFORMAT: HHMMREQUIREDGS07Responsible Agency CodeMID1/2Code identifying the issuer of the standardCodeDefinitionCommentsXAccredited Standards Committee X12REQUIREDGS08Version / Release / Industry Identifier CodeMID1/2CodeDefinitionComments005010X220A1Standards Approved for Publication by ASC X12 Procedures Review BoardST - Transaction Set HeaderX12 Segment Name:Transaction Set HeaderX12 Purpose: To indicate the start of a transaction set and to assign a control numberSegment Repeat: 1Usage: REQUIREDExample:ST?834?0001?005010X220A1~ST?ST01143Trans Set Identifier CodeMID3/3?ST02329Trans Sent Control NumberMAN4/9?ST031705Implement Conv ReferenceOAN1/35~USAGEREF.DES.Name AttributesREQUIREDST01Transaction Set Identifier Code MID3/3Code uniquely identifying a Transaction SetCodeDefinitionComments834Benefit Enrollment and MaintenanceREQUIREDST02Transaction Set Control Number MAN4/9Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set. The number must be identical to the SE02 data element as defined in section 2.2.28 on pages 29 and 30.REQUIREDST03Implementation Convention Reference OAN1/35CodeDefinitionComments005010X220A1Standards Approved for Publication by ASC X12 Procedures Review BoardBGN - Beginning SegmentX12 Segment Name:Beginning SegmentX12 Purpose: To indicate the beginning of a transaction setSegment Repeat: 1Usage: REQUIREDExample:BGN?00?XXXX?19970920?120001?CT???2~BGN *BGN01353TS Purpose CodeMID2/2*BGN02127Reference IdentifierMAN1/50*BGN03337DateMDT8/8*BGN04337TimeXTM4/8*BGN05623Time CodeOID2/2*BGN06127Reference IdentificationOAN1/50*BGN07640Transaction Type CodeOID2/2*BGN008306Action CodeOID1/2~UsageREF.DES.Name AttributesREQUIREDBGN01Transaction Set Purpose Code MID2/2Code identifying purpose of transaction setCodeDefinitionComments00OriginalREQUIREDBGN02Reference IdentificationMAN1/50Reference information as defined for a particular Transaction Set or as specified by the Reference Identification QualifierREQUIREDBGN03DateMDT8/8Functional Group Creation DateFORMAT:CCYYMMDDREQUIREDBGN04TimeMTM4/8Transaction set creation timeFORMAT:HHMMSSSITUATIONALBGN05Time CodeOID2/2Time Zone???CodeDefinitionCommentsCTCentral Time???SITUATIONALBGN06Reference Identification OAN1/50Not UsedNOT USEDBGN07Transaction Type Code OID1/50Not UsedREQUIREDBGN08Action CodeOID1/2Code indicating type of action???CodeDefinitionComments2Change/UpdateUsed to identify a transaction of additions, terminations and changes to the current enrollment.4VerifyUsed to identify a full enrollment transaction to verify that the sponsor’s and payer’s systems are synchronized.RXAC/TC ReconQuarterly reconciliation of AC/TC history.???DTP – File Effective DateX12 Segment Name:Date or Time or PeriodX12 Purpose: To specify any or all of a date, a time, or a time periodSegment Repeat: >1Usage:SITUATIONALExample:DTP?007?D8?19960101~DTP *DTP01374Date/Time QualifierMID3/3*DTP021250Date Time Period Format QualifierMAN1/50*BGN03337Date Time PeriodMDT8/8~UsageREF.DES.Name AttributesREQUIREDDTP01Date/Time Qualifier MID3/3Code specifying type of date or time, or both date and timeCodeDefinitionComments007EffectiveREQUIREDDTP02Date Time Period Format Qualifier MID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDREQUIREDDTP03Date Time PeriodMAN1/35Expression of a date.N1 – Sponsor NameX12 Segment Name:Party IdentificationX12 Purpose: To identify a party by type of organization, name, and codeLoop:1000ALoop Repeat:1Segment Repeat: 1Usage: REQUIREDExample:N1?P5??24?12356799~N1 *N10198Entity ID CodeMID2/3*N10293NameXAN1/60*N10366ID Code QualifierXID1/2*N10467ID CodeXAN2/80~UsageREF.DES.Name AttributesREQUIREDN101Entity Identifier Code MID2/3Code identifying an organizational entity, a physical location, property or an individualCodeDefinitionCommentsP5Plan SponsorSITUATIONALN102NameXAN1/60Not SentREQUIREDN103Identification Code Qualifier XID1/2CodeDefinitionCommentsFIFederal Taxpayer’s Identification NumberREQUIREDN104Identification Code XAN2/80Identification Code sent 726011595N1 – PayerX12 Segment Name:Party IdentificationX12 Purpose: To identify a party by type of organization, name, and codeLoop:1000BLoop Repeat:1Segment Repeat: 1Usage: REQUIREDExampleN1?IN? ?FI?12356789~N1 *N10198Entity IDCodeMID2/3*N10293NameXAN1/50*N10366ID Code QualifierXID1/2*N10467ID CodeXAN2/80~UsageREF.DES.Name AttributesREQUIREDN101Entity Identifier Code MID2/3Code identifying an organizational entity, a physical location, property or an individualCodeDefinitionCommentsINInsurerSITUATIONALN102NameXAN1/60Not UsedREQUIREDN103Identification Code Qualifier XID1/2CodeDefinitionCommentsFIFederal Taxpayer’s Identification NumberREQUIREDN104Identification Code XAN2/80Identification Code sent BAYOU HEALTH PLAN’s Federal Tax IDINS – Member Level DetailX12 Segment Name:Insured BenefitX12 Purpose: To provide benefit information on insured entitiesLoop:2000 - Member Level DetailLoop Repeat:> 1Segment Repeat: 1Usage:REQUIREDExample:INS*Y*18*024*XT*A***AC**N~INS *INS011073Yes/No Cond Resp CodeMID1/1*INS021069Individual Relation CodeMID2/2*ISN03875Maintenance Type CodeOID3/3*INS041203Maintain Reason CodeOID2/3*INS051216Benefit Status CodeOID1/1*INS06C052Medicare Status CodeO*INS071219COBRA Qual Event CodeOID1/2*INS08584Employment Status CodeOID2/2*INS091220Student Status CodeOID1/1*INS101073Handicap IndicatorOID1/1*INS111250Date Time Format QualOID2/3*INS111251Date of DeathOAN1/35~UsageREF.DES.Name AttributesREQUIREDINS01Member IndicatorMID1/1Indicates the person is a subscriber (all records for Medicaid are subscribers).CodeDefinitionCommentsYYesIndicates the person is a subscriberREQUIREDINS02Individual Relationship Code MID2/2Code indicating the relationship between two individual entities.CodeDefinitionComments18SelfValue 18 must be used for a subscriberREQUIREDINS03Implementation Convention Reference Maintenance Type Code OID3/3Code identifying the specific type of item maintenanceCodeDefinitionComments001Change021Addition024Cancel or Termination030Audit or CompareSITUATIONALINS04Maintenance Reason Code OID2/3Code identifying the reason for the maintenance change (See Appendix D for a full mapping of MAXIMUS enrollment, disenrollment, and maintenance reasons to 834 maintenance reason codes)CodeDefinitionComments03Death07Termination of Benefits14Voluntary Withdrawal25Change in Identifying Data Elements26Declined CoverageAHPatient Moved to a New LocationAINo Reason GivenALAlgorithm Assigned Benefit SelectionECMember Benefit SelectionXNNotification OnlyXTTransferREQUIREDINS05Benefit Status Code OID1/1The type of coverage under which benefits are paidCodeDefinitionCommentsAActiveSITUATIONALINS06MEDICARE STATUS CODE ONot SentSITUATIONALINS07Consolidated Omnibus Budget Reconciliation Act (COBRA) QualifyingOID1/2Not UsedSITUATIONALINS08Employment Status Code OID2/2Required because transaction is for a subscriber. The data element will contain the status of the member in the program, rather than employment status.CodeDefinitionCommentsACActiveMedicaid Managed Care participantTETerminatedNot a Medicaid managed Care participantSITUATIONALINS09Student Status Code OID1/1Not UsedSITUATIONALINS10Handicap IndicatorOID1/1Special Needs IndicatorCodeDefinitionCommentsNNoYYesSITUATIONALINS11Date Time Period Format Qualifier XID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDSITUATIONALINS12Date of DeathXAN1/35Member Individual Death Date. Required if the member is deceased. This does not replace the use of the termination date within the 2300 loop.REF – Subscriber IdentifierX12 Segment Name:Reference InformationX12 Purpose: To specify identifying informationLoop:2000 - Member Level DetailSegment Repeat: 1Usage:REQUIREDExample:REF?0F?1111111111111~REF *REF01353TS Purpose CodeMID2/2*REF02127Reference IdentifierXAN1/50~UsageREF.DES.Name AttributesREQUIREDREF01Reference Identification Qualifier MID2/3Code qualifying the Reference IdentificationCodeDefinitionComments0FSubscriber NumberREQUIREDREF02Reference Identification MAN1/50Identifying subscriber identifier is 13-digit Louisiana Medicaid Recipient ID NumberREF – Member Policy NumberX12 Segment Name:Reference InformationX12 Purpose: To specify identifying information. Required when the policy number applies to all coverage data (all 2300 loops for this member).Loop:2000 - Member Level DetailSegment Repeat: 1Usage:REQUIREDExample:REF?1L?1726011595~REF *REF01353TS Purpose CodeMID2/2*REF02127Reference IdentifierXAN1/50~UsageREF.DES.Name AttributesREQUIREDREF01Reference Identification Qualifier MID2/3Code qualifying the Reference IdentificationCodeDefinitionComments1LGroup or Policy NumberREQUIREDREF02Reference Identification MAN1/50Policy number with a value of 1726011595REF – Member Supplemental IdentifierX12 Segment Name:Reference InformationX12 Purpose: To specify identifying informationLoop:2000 - Member Level DetailSegment Repeat: 13Usage:SITUATIONALExample:REF?23?2222222222222222~ REF *REF01128Reference Ident QualifierMID2/3*REF02127Reference IdentifierMAN1/50~UsageREF.DES.Name AttributesREQUIREDREF01Reference Identification Qualifier MID2/3Code qualifying the Reference IdentificationCodeDefinitionComments23Client Number3HCase Number6OCross Reference Number (Type Case)ZZMutually definedMother’s reference ID for newbornsREQUIREDREF02Reference Identification MAN1/50Value to be supplied – to match code definition.DTP – Member Level DatesX12 Segment Name:Date or Time or PeriodX12 Purpose: To specify any or all of a date, a time, or a time periodLoop:2000 - Member Level DetailSegment Repeat: 3Usage:SITUATIONALExample:DTP?473?D8?19960705~DTP *DTP374Date/Time QualifierMID3/3*DTP021250Date Time Format QualifierMID2/3*DTP031251DateMAN1/35~UsageREF.DES.Name AttributesREQUIREDDTP01Date/Time Qualifier MID3/3Code specifying type of date or time, or both date and timeCodeDefinitionComments473Medicaid Begin474Medicaid EndREQUIREDDTP02Date Time Period Format Qualifier MID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDREQUIREDDTP03Date Time PeriodMAN1/35Status Information Effective DateDTP *DTP374Date/Time QualifierMID3/3*DTP021250Date Time Format QualifierMID2/3*DTP031251DateMAN1/35~UsageREF.DES.Name AttributesREQUIREDDTP01Date/Time Qualifier MID3/3Code specifying type of date or time, or both date and timeCodeDefinitionComments356PBS Eligibility Begin Date357PBS Eligibility End DateREQUIREDDTP02Date Time Period Format Qualifier MID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDREQUIREDDTP03Date Time PeriodMAN1/35Status Information Effective DateNM1 – Member NameX12 Segment Name:Individual or Organizational NameX12 Purpose: To supply the full name of an individual or organizational entityLoop:2100A - Member NameLoop Repeat:1Segment Repeat: 1Usage:RequiredExample:NM1?IL?1?SMITH?JOHN?M??SR~NM1 *NM10198Entity ID CodeMID2/3*NM1021065Entity Type QualifierMID1/1*NM1031035Last NameXAN1/60*NM1041036First NameOAN1/35*NM1051037Middle NameOAN1/10*NM1061038Name PrefixOAN1/10*NM1071039Name SuffixOAN1/10*NM10866ID Code QualifierXID1/2*NM10967ID CodeXAN2/80~UsageREF.DES.Name AttributesREQUIREDNM101Entity Identifier Code MID2/3Code specifying type of date or time, or both date and timeCodeDefinitionCommentsILInsured or SubscriberREQUIREDNM102Entity Type Qualifier MID1/1Code qualifying the type of entityCodeDefinitionComments1PersonREQUIREDNM103Name Last or Organization NameXAN1/60Member Last NameSITUATIONALNM104Name FirstOAN1/35Member First NameSITUATIONALNM105Name MiddleOAN1/25Member Middle Name or Middle InitialSITUATIONALNM106Name PrefixOAN1/10Not UsedSITUATIONALNM107Name SuffixOAN1/10Suffix to individual nameSITUATIONALNM108Identification Code Qualifier XID1/2Code designating the system/method of code structure used for Identification Code.??CodeDefinitionComments34Social Security NumberSITUATIONALNM109Identification CodeXAN2/80Member Social Security NumberPER – Member Communication NumbersX12 Segment Name:Administrative Communications ContactX12 Purpose: To identify a person or office to whom administrative communications should be directedLoop:2100A - Member NameSegment Repeat: 1Usage:SITUATIONALExample:PER?IP??TE?8015554321~PER *PER01366Contact Function CodeMID2/2*PER0293NameOAN1/60*PER03365Comm Number QualifierMID2/2*PER04364Communication NumberXAN1/256*PER05365Comm Number QualifierXID2/2*PER06364Communication NumberXAN1/256*PER07365Comm Number QualifierXIDX*PER08364Communication NumberXANX~UsageREF.DES.Name AttributesREQUIREDPER01Contact Function Code MID2/2Code identifying the major duty or responsibility of the person or group namedCodeDefinitionCommentsIPInsured PartyNOT USEDPER02NameOAN1/60Not UsedREQUIREDPER03Communication Number Qualifier XID2/2Code identifying the type of communication number??CodeDefinitionCommentsAPAlternate PhoneHPHome PhoneTETelephone???REQUIREDPER04Communication Number XAN1/256Code identifying the type of communication numberSITUATIONALPER05Communication Number Qualifier XID2/2Code identifying the type of communication number??CodeDefinitionCommentsAPAlternate PhoneHPHome PhoneTETelephone???SITUATIONALPER06Communication Number XAN1/256Code identifying the type of communication numberSITUATIONALPER07Communication Number Qualifier XID2/2Code identifying the type of communication number??CodeDefinitionCommentsAPAlternate PhoneHPHome PhoneTETelephone???SITUATIONALPER08Communication Number XAN1/256Code identifying the type of communication numberN3 – Member Residence Street AddressX12 Segment Name:Party LocationX12 Purpose: To specify the location of the named partyLoop:2100A - Member NameSegment Repeat: 1Usage:SITUATIONALExample:N3?50 ORCHARD STREET~N3 *N301166Address InformationMAN1/55*N302166Address InformationOAN1/55~UsageREF.DES.Name AttributesREQUIREDN301Address Information MAN1/55Member Address LineSITUATIONALN302Address Information OAN1/55Second Member Address LineN4 – Member City, State, Zip CodeX12 Segment Name:Geographic LocationX12 Purpose: To specify the geographic place of the named partyLoop:2100A - Member NameSegment Repeat: 1Usage:REQUIREDExample:N4?LAFAYETTE?LA?12345~N4 *N40119CityOAN2/30*N402156State CodeXID2/2*N403116Postal CodeOID3/15~UsageREF.DES.Name AttributesREQUIREDN401City NameOAN2/30City NameSITUATIONALN402State or Province Code XID2/2Code (Standard State/Province) as defined by appropriate government agencySITUATIONALN403Postal CodeOID3/15Code defining international postal zone code excluding punctuation and blanks (zip code for United States)DMG – Member DemographicsX12 Segment Name:Demographic InformationX12 Purpose: To supply demographic informationLoop:2100A - Member NameSegment Repeat: 1Usage:SITUATIONALExample:DMG?D8?19450915?F?M~DMG *DMG011250Date Time Format QualXID2/3*DMG021251Birth DateXAN1/35*DMG031068Gender CodeOID1/1*DMG041067Marital Status CodeOID1/1*DMG05C056Comp Race or Ethnic InfoX~UsageREF.DES.Name AttributesREQUIREDDMG01Date Time Period Format Qualifier XID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDREQUIREDDMG02Date Time Period XAN1/35Member Birth DateREQUIREDDMG03Gender CodeOID1/1Code indicating the sex of the individualCodeDefinitionCommentsFFemaleMMaleUUnknownSITUATIONALDMG04Marital StatusOID1/1Not UsedSITUATIONALDMG05Composite Race or Ethnicity InformationX10To send general and detailed information on race or ethnicitySITUATIONALDMG05-1Race or Ethnicity CodeOID1/1Code Indicating Race or Ethnicity. See Appendix A Race Codes and crosswalk to LA specific Race Codes.??CodeDefinitionCommentsSITUATIONALDMG05-2Code List QualifierXID1/3Code indicating specific Industry Code ListCodeDefinitionCommentsRETClassification of Race or EthnicitySITUATIONALDMG05-3Industry CodeXID1/3Code indicating specific Industry Code ListLUI – Member LanguageX12 Segment Name:Language UseX12 Purpose: To specify language, type of usage and proficiency or fluencyLoop:2100 - Member NameSegment Repeat: >1Usage:SITUATIONALExample:LUI?LE?EN??7~LUI *LUI0166ID Code QualifierXID1/2*LUI0267IDCodeMAN1/50*LUI03352DescriptionXAN1/80*LUI041303Use of Language IndXTM4/8~UsageREF.DES.Name AttributesSITUATIONALLUI01Identification Code Qualifier XID1/2CodeDefinitionCommentsLEISO 639 Language CodesSITUATIONALLUI02Identification CodeMID2/2Language Code, see list.CodeDefinitionLA CodeENEnglish01ESSpanish02ARArabic04HYChinese19FAPersian07FRFrench08DEGerman09ELGreek10HTHaitian Creole11HIHindi12ITItalian14JAJapanese15KMKhmer16KOKorean17LOLao18PLPolish20PTPortuguese21RURussian22SMSamoan23TLTagalog24VIVietnamese25YIYiddish26SITUATIONALLUI03DescriptionXAN1/80Language DescriptionSITUATIONALLUI04Use of Language IndicatorOID1/2Code indicator of use of a languageCodeDefinitionComments7SpeakingNM1 – Member Mailing AddressX12 Segment Name:Individual or Organizational NameX12 Purpose: To supply the full name of an individual or organizational entityLoop:2100C - Member Mailing AddressLoop Usage:SITUATIONALLoop Repeat:1Segment Repeat: 1Usage:SITUATIONALExample:NM1?31?1~NM1 *NM10198Entity IDCodeMID2/3*NM1021065Entity Type QualifierMID1/2~UsageREF.DES.Name AttributesREQUIREDNM101Entity Identifier Code MID2/3Code specifying type of date or time, or both date and timeCodeDefinitionComments31Postal Mailing AddressREQUIREDNM102Entity Type Qualifier MID1/1Code qualifying the type of entityCodeDefinitionComments1PersonN3 – Member Mail Street AddressX12 Segment Name:Party LocationX12 Purpose: To specify the location of the named partyLoop:2100C - Member Mailing AddressSegment Repeat: 1Usage:REQUIREDExample:N3?50 ORCHARD STREET~N3 *N301166Address InformationMAN1/55*N302166Address InformationOAN1/55~USAGEREF.DES.Name AttributesREQUIREDN301Address Information MAN1/55Member Address LineSITUATIONALN302Address Information OAN1/55Second Member Address LineN4 – Member Mail City, State, Zip CodeX12 Segment Name:Geographic LocationX12 Purpose: To specify the geographic place of the named partyLoop:2100C - Member Mailing AddressSegment Repeat: 1Usage:REQUIREDExample:N4?LAFAYETTE?LA?12345~N4 *N40119CityOAN2/30*N402156State CodeXID2/2*N403116Postal CodeOID3/15~UsageREF.DES.Name AttributesREQUIREDN401City NameOAN2/30City NameSITUATIONALN402State or Province Code XID2/2Code (Standard State/Province) as defined by appropriate government agencySITUATIONALN403Postal CodeOID3/15Code defining international postal zone code excluding punctuation and blanks (zip code for United States)NM1 – Responsible PersonX12 Segment Name:Individual or Organizational NameX12 Purpose: To supply the full name of an individual or organizational entityLoop:2100G — RESPONSIBLE PERSONLoop Usage:SITUATIONALLoop Repeat:1Segment Repeat: 1Usage:SITUATIONALExample:NM1?QD?1?CASE?JOHN???34?123121234~NM1?NM10198Entity ID CodeMID2/3?NM1021065Entity Type QualifierMID1/1?NM1031036Last NameMAN1/60?NM1041036First NameOAN1/35?NM1051037Middle NameOAN1/25?NM1061038Name PrefixOAN1/10?NM1071039Name SuffixOAN1/10?NM10866Identification Code IdentifierXID??NM10967Social Security NumberXAN2/80~USAGEREF.DES.Name AttributesREQUIREDNM101Entity Identifier Code MID2/3Code specifying type of date or time, or both date and timeCodeDefinitionCommentsQDResponsible PartyREQUIREDNM102Entity Type Qualifier MID1/1Code qualifying the type of entityCodeDefinitionComments1PersonREQUIREDNM103Name Last or Organization NameXAN1/60Individual Last Name or organizational nameSITUATIONALNM104Name FirstOAN1/35Individual First NameSITUATIONALNM105Name MiddleOAN1/25Individual Middle InitialSITUATIONALNM106Name PrefixOAN1/10Not UsedSITUATIONALNM107Name SuffixOAN1/10Not UsedSITUATIONALNM108Identification Code Qualifier XID1/2CodeDefinitionComments34Social Security NumberSITUATIONALNM109Identification Code XAN2/80Responsible Party IdentifierHD – Health CoverageX12 Segment Name:Individual or Organizational NameX12 Purpose: To supply the full name of an individual or organizational entityLoop:2300 - HEALTH COVERAGELoop Repeat:99Segment Repeat: 1Usage:SITUATIONALExample:HD?021??HMO?0105C-C?IND~HD *HD01875Maintenance Type CodeMID3/3*HD021203Maintenance Reason CodeOID2/3*HD0312p5Insurance Line CodeMID2/3*HD041204Plan Coverage DescriptionOAN1/50*HD05051207Coverage Level CodeOID3/3~USAGEREF.DES.Name AttributesREQUIREDHD01Maintenance Type Code MID3/3Code identifying the specific type of item maintenanceCodeDefinitionComments001Change021Addition024Cancellation or termination025Reinstatement030Audit or CompareNOT USEDHD02Maintenance Reason Code OID2/3Not UsedREQUIREDHD03Insurance Line Code OID2/3Code identifying a group of insurance products??CodeDefinitionCommentsHMOHealth Maintenance OrganizationSITUATIONALHD04Plan Coverage Description OAN1/50Capitation Code (See Appendix C) and Choice/Auto Enrollment indicator separated by a -. Type of enrollment is only sent on newly added enrollments.CodeDefinitionCommentsCChoice EnrollmentAAuto EnrollmentEOpen EnrollmentAdded in version 2.17SITUATIONALHD05Coverage Level CodeOID3/3Code identifying a group of insurance products??CodeDefinitionCommentsINDIndividualDTP – Health Coverage DatesX12 Segment Name:Date or Time or PeriodX12 Purpose: To specify any or all of a date, a time, or a time periodLoop:2300 - HEALTH COVERAGESegment Repeat: 6Usage:REQUIREDExample:DTP?348?D8?19961001~SPECIAL NOTE:The benefits begin and end dates will contain a span of coverage for the quarterly AC/TC reconciliation file and not a month by month listing. DTP *DTP374Date/Time QualifierMID3/3*DTP021250Date Time Format QualifierMID2/3*DTP031250Date Time PeriodMAN1/35~USAGEREF.DES.Name AttributesREQUIREDDTP01Date/Time Qualifier MID3/3Code specifying type of date or time, or both date and timeCodeDefinitionComments348Benefit BeginThe 348 date will also be considered as the start date for the AC/TC reconciliation file.349Benefit EndREQUIREDDTP02Date Time Period Format Qualifier MID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsD8Date Expressed in Format CCYYMMDDREQUIREDDTP03Date Time PeriodMAN1/35Coverage PeriodREF – Health Coverage Policy NumberX12 Segment Name:Reference InformationX12 Purpose: To specify identifying informationLoop:2300 – Health CoverageSegment Repeat: 14Usage:SITUATIONALExample:REF?ZX?1 ~ REF *REF01126Reference Ident QualifierMID2/3*REF02127Reference IdentificationMAN1/50~USAGEREF.DES.Name AttributesREQUIREDREF01Reference Identification Qualifier MID2/3Code qualifying the Reference Identification CodeDefinitionCommentsM7Medical Assistance CategoryAid CategoryZXCounty CodeParish CodeREQUIREDREF02Reference Identification MAN1/50See Appendix B for table of Parish Codes and Appendix E for Aid Category Codes.LX – Provider InformationX12 Segment Name:Transaction Set Line NumberX12 Purpose: To reference a line number in a transaction setLoop:2310 - Provider InformationLoop Repeat:30Segment Repeat: 1Usage:SITUATIONALExample:LX*1~LX *LX01554Assigned NumberMN01/6~USAGEREF.DES.Name AttributesREQUIREDLX01Assigned Number MNO1/6Number assigned for differentiation within a transaction setNM1 – Provider NameX12 Segment Name:Individual or Organizational NameX12 Purpose: To supply the full name of an individual or organizational entityLoop:2310 - Provider InformationSegment Repeat: 1Usage:REQUIREDExample:NM1?P3?1?OLSON?HENRY?L???XX?25341234567~NM1 *NM10198Entity ID CodeMID2/3*NM1021065Entity Type QualifierMID1/1*NM1031035Last Name/ Org NameXAN1/60*NM1041036First NameOAN1/35*NM1051037Middle NameOAN1/25*NM1061038Name PrefixOAN1/10*NM1071039Name SuffixOAN1/10*NM10866ID CodeQualifierXAN1/2*NM10967IDCodeXID2/80*NM110706Entity Relation CodeXID2/2~USAGEREF.DES.Name AttributesREQUIREDNM101Entity Identifier Code MID2/3Code specifying type of date or time, or both date and timeCodeDefinitionCommentsP3Primary Care ProviderREQUIREDNM102Entity Type Qualifier MID1/1Code qualifying the type of entityCodeDefinitionComments1Person2Non-Person EntityREQUIREDNM103Name Last or Organization NameXAN1/60Individual Last Name or organizational nameSITUATIONALNM104Name FirstOAN1/35Individual First NameSITUATIONALNM105Name MiddleOAN1/25Individual Middle InitialSITUATIONALNM106Name PrefixOAN1/10???Not UsedSITUATIONALNM107Name SuffixOAN1/10Not UsedSITUATIONALNM108Identification Code Qualifier XID?CodeDefinitionCommentsSVService Provider NumberXXNational Provider IdentifierSITUATIONALNM109Identification Code XAN2/80Provider IdentifierREQUIREDNM110Entity Relationship CodeXAN2/80Code describing entity relationshipCodeDefinitionComments72UnknownLS – Additional Reporting CategoriesX12 Segment Name:Loop HeaderX12 Purpose: To indicate that the next segment begins a loopLoop:2000 – Member Level DetailSegment Repeat: 1Usage:SITUATIONALLS*2700~NOTE: The 2700 loop referenced in sections 2.28 through 2.33 will only be sent in the monthly recon file and not in daily files.LS *LS01447Loop ID CodeM1AN1/4~USAGEREF.DES.Name AttributesREQUIREDLS01Loop Identifier Code M1AN1/4The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LELX – Member Reporting CategoriesX12 Segment Name:Transaction Set Line NumberX12 Purpose: To reference a line number in a transactionLoop:2700 – Member Reporting CategoriesLoop Repeat:>1Segment Repeat: 1Usage:SITUATIONALExample:LX?1~LX *LX01554Assigned NumberM1N01/6~USAGEREF.DES.Name AttributesREQUIREDLX01Assigned Number M1N01/6Number assigned for differentiation within a transaction setN1 – Reporting CategoryX12 Segment Name:Reporting CategoryX12 Purpose: To identify a party by type of organization, name, and codeLoop:2750 – Reporting CategoryLoop Repeat:1Segment Repeat: 1Usage:SITUATIONALExample:N1*75*LA Medicaid History~N1 *N101Entity ID CodeM1ID2/3*N102NameX1AN1/60~USAGEREF.DES.Name AttributesREQUIREDN101Entity ID CodeM1ID2/3Code Identifying OrganizationCodeDefinitionComments75ParticipantREQUIREDN102NameX1AN1/60Member Reporting Category Name use LA Medicaid HistoryREF – Reporting Category ReferenceX12 Segment Name:Reference InformationX12 Purpose: To specify Identifying informationSegment Repeat: 1Usage:SITUATIONALExample:REF*ZZ*002/03~NOTE: The REF *REF01Reference Ident QualM1ID2/3*REF02Reference IdentX1AN1/50~USAGEREF.DES.Name AttributesREQUIREDREF01Reference Identification QualifierM1ID2/3Code qualifying the reference identificationCodeDefinitionCommentsZZMutually DefinedREQUIREDREF02Reference IdentificationX1AN1/50Type Case/Aid CategoryDTP – Report Category DateX12 Segment Name:Date or Time PeriodX12 Purpose: To specify any or all of a date, a time, or a time periodSegment Repeat: 1Usage:SITUATIONALExample:DTP*007*RD8*20100101-20120131~DTP *DTP01Date/Time QualifierMID3/3*DTP02Date Time Format QualifierMID2/3*DTP03Date Time PeriodMAN1/35~USAGEREF.DES.Name AttributesREQUIREDDTP01Date/Time Qualifier MID3/3Code specifying type of date or time, or both date and timeCodeDefinitionComments007EffectiveREQUIREDDTP02Date Time Period Format Qualifier MID2/3Code indicating the date format, time format, or date and time formatCodeDefinitionCommentsRD8Range of Dates Expressed in Format CCYYMMDD- CCYYMMDDREQUIREDDTP03Date Time PeriodMAN1/35Member Reporting Category Effective DatesLE – Additional Reporting Categories Loop TerminationX12 Segment Name:Loop TrailerX12 Purpose: To indicate the loop immediately preceding this segment is completeLoop:2000 – Member Level DetailSegment Repeat: 1Usage:SITUATIONALExample:LE?2700~LE *LE01Loop IDM1AN1/4~USAGEREF.DES.Name AttributesREQUIREDLE01Loop Identifier CodeMAN?Use 2700SE – Transaction Set TrailerX12 Segment Name:Transaction Set TrailerX12 Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)Segment Repeat: 1Usage: REQUIREDExample:SE?39?0001~SE *SE01Number of Included SegMN01/10*SE02Trans Set Control NumberMAN4/9~USAGEREF.DES.Name AttributesREQUIREDSE01Number of Included SegmentsMN01/10Total number of segments included in a transaction set including ST and SE segmentsREQUIREDSE02Transaction Set Control Number MAN4/9Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction setGE –Functional Group TrailerX12 Segment Name:Functional Group TrailerX12 Purpose: To indicate the end of a functional group and to provide control informationSegment Repeat: 1Usage: REQUIREDExample:GE?1?1~GE *GE01353Number of TS Sets IncludedMN01/6*GE02Group Control NumberMN01/9~USAGEREF.DES.Name AttributesREQUIREDGE01Number of Transaction Sets Included MN01/6Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data elementREQUIREDGE02Group Control NumberMN01/9Assigned number originated and maintained by the senderIEA –Interchange Control TrailerX12 Segment Name:Interchange Control TrailerX12 Purpose: To define the end of an interchange of zero or more functional groups andinterchange-related control segmentsSegment Repeat: 1Usage: REQUIREDExample:IEA?1?000000905~IEA *IEA01Number of Functional GrpsMN01/5*IEA02Interchange Control NumberMN09/9~USAGEREF.DES.Name AttributesREQUIREDIEA01Number of Included Functional Groups MN01/5A count of the number of functional groups included in an interchangeREQUIREDIEA02Interchange Control Number MN09/9A control number assigned by the interchange senderTestingOnce testing begins, files will be posted on the Xchange website. An email notification will be sent to the email address provided by the Trading Partner.Xchange GatewayAll test files will be loaded to the Xchange Gateway for each Trading Partner to download. Xchange Gateway ServerThe Xchange Gateway server is a centralized, secure, external file drop server. Each Trading Partner will have a mailbox and folder directory structure, located on the Xchange Gateway Server; which allows for plans to upload and download files.AccessThe Xchange Gateway server can be accessed through https using a web browser or SFTP using a SFTP client. Although note that changing passwords must be done through the web browser.Using Web BrowserUsing Internet Explorer or Firefox go to the following URL. Using SFTP ClientSFTP Clients are supported; FileZilla is a tested and supported option.User Account ActivationTo obtain an Account for the 834 Testing please email Xchange@ specifying the following information. Accounts are not meant to be shared, so for multiple users, please request multiple logins.Full Name:?Email Address:?Health Plan:?Purpose:5010 Testing for the LA EB ProjectSelf Service Password AdministrationXchange will allow for 5 login attempts before the user is secretly locked out. No indication will be made to the user that their account has been locked out for security purposes; only the Xchange administrative team will be notified. If you believe you have forgotten your password, a password reset can be requested automatically from the Xchange Server Login Web Page.Connectivity IssuesPlease contact Xchange@ if you experience any difficulty with the Xchange Gateway.File LocationsTrading Partner’s home directory will contain an outbound folder. All X12 test files will be placed in the test folder under the outbound folder.Appendix A – Ethnicity CodesConversion of Ethnicity Codes from the LA MMIS to the 834 Race and Ethnicity Code set. Codes should be interpreted with the LA Description as shown bolded below the 834 code set definition.834 CodeDescriptionLA Code7Not Provided9(UNKOWN)AAsian or Pacific Islander4(ASIAN)BBlack2(BLACK OR AFRICAN AMERICAN)EOther Race or Ethnicity8(MORE THAN ONE RACE INDICATED (AND NOT HISPANIC OR LATINO)HHispanic5(HISPANIC OR LATINO (NO OTHER RACE INFO)) IAmerican Indian or Alaskan Native3(AMERICAN INDIAN OR ALASKAN NATIVE )JNative Hawaiian6(NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER)OWhite (Non-Hispanic)1(WHITE)ZMutually Defined 7(HISPANIC OR LATINO AND ONE OR MORE OTHER ) Appendix B – Parish CodesTable consists of Louisiana Paris Codes and their corresponding Medicaid Regions.Parish CodeRecipient Parish DescriptionRecipient Medicaid Region1ACADIA42ALLEN53ASCENSION24ASSUMPTION35AVOYELLES66BEAUREGARD57BIENVILLE78BOSSIER79CADDO710CALCASIEU511CALDWELL812CAMERON513CATAHOULA614CLAIBORNE715CONCORDIA616DESOTO717EAST BATON ROUGE218EAST CARROLL819EAST FELICIANA220EVANGELINE421FRANKLIN822GRANT623IBERIA424IBERVILLE225JACKSON826JEFFERSON127JEFFERSON DAVIS528LAFAYETTE429LAFOURCHE330LASALLE631LINCOLN832LIVINGSTON933MADISON834MOREHOUSE835NATCHITOCHES736ORLEANS137OUACHITA838PLAQUEMINES139POINTE COUPEE240RAPIDES641RED RIVER742RICHLAND843SABINE744ST BERNARD145ST CHARLES346ST HELENA947ST JAMES348ST JOHN349ST LANDRY450ST MARTIN451ST MARY352ST TAMMANY953TANGIPAHOA954TENSAS855TERREBONNE356UNION857VERMILION458VERNON659WASHINGTON960WEBSTER761WEST BATON ROUGE262WEST CARROLL863WEST FELICIANA264WINN665EAST JEFFERSON177Out-of-Staten/aAppendix C – Capitation codesCapitation codes derived from aid category, type case, age, and gender.Capitation CodePlan Service Type0105CBAYOUHEALTH-P0103CBAYOUHEALTH-P0206FBAYOUHEALTH-P0205MBAYOUHEALTH-P04BLLBAYOUHEALTH-P0203CBAYOUHEALTH-P0207MBAYOUHEALTH-P0106CBAYOUHEALTH-P0104CBAYOUHEALTH-P0206MBAYOUHEALTH-P0101CBAYOUHEALTH-P0102CBAYOUHEALTH-P0202CBAYOUHEALTH-P0204CBAYOUHEALTH-P03FLLBAYOUHEALTH-P0107CBAYOUHEALTH-P0201CBAYOUHEALTH-P0207FBAYOUHEALTH-P0205FBAYOUHEALTH-PCCNS1BAYOUHEALTH-SCCNS2BAYOUHEALTH-SAppendix D – Maintenance Reason CodesCross reference table for possible maintenance reason codes and the codes sent in the 834.MAXIMUS CodeMAXIMUS Reason Description834 codeMaintenance Reason description0Not applicable (use when not a disenrollment record)AINo Reason Given9Recipient has other health insurance7Termination of Benefits18Recipient moved out of service areaAHPatient Moved to a New Location20Recipient does not meet LOC criteria7Termination of Benefits40Voluntary disenrollment14Voluntary Withdrawal48Death of recipient, DOD unknown3Death68Involuntary disenrollment7Termination of Benefits77Recipient admitted to institution7Termination of Benefits78Recipient moved out of stateAHPatient Moved to a New Location8790 Day Enrollment Grace PeriodXTTransfer90Death of recipient3Death100Recipient is not categorically eligibile7Termination of Benefits211Retroactively Disenroll Newborns7Termination of Benefits310DHH special insertion of DE7Termination of Benefits311DHH special cancellation of IE7Termination of Benefits312DHH special cancellation of DE7Termination of Benefits700Member requests to be assigned to the same CCN as family membersAINo Reason Given701The member needs related services to be performed at the same timeAINo Reason Given702Poor quality of careAINo Reason Given703Lack of access to services covered under the contractAINo Reason Given704Documented lack of access to providers experienced in dealing with the member healthcare needsAINo Reason Given801To implement the decision of a hearing officerAINo Reason Given802Member intentional submission of fraudulent information;AINo Reason Given803Member is incarcerated;AINo Reason Given804Member is placed in a long term care facility (nursing facility or intermediate care facility for persons with developmental disabilities);AINo Reason Given805Member is enrolled in a Medicaid home and community-based services waiver(HDBS) ;AINo Reason Given806The entity does not, because of moral or religious objections, cover the service the member seeks; AINo Reason Given807The contract between the entity and DHH is terminated;AINo Reason Given808The member is placed in a nursing facility or intermediate care facility for individuals with developmental disabilities;AINo Reason Given900Opt-out, Native American Tribal Registered26Declined Coverage901Opt-out, Foster Care individual26Declined Coverage902Opt-out, OYD/OJJ individual26Declined Coverage903Opt-out, recipient < 19 with spec serv26Declined Coverage904Opt-out, SSI recipient26Declined Coverage905Opt-out, Other reason.26Declined Coverage906Disenrollment during Annual Enrollment.26Declined CoverageAppendix D – Maintenance Reason Codes – ContinuedCross reference table for possible maintenance reason codes and the codes sent in the 834.MAXIMUS CodeMAXIMUS Reason Description834 codeMaintenance Reason description907Disenrolled due to Hospice admission7Termination of Benefits908Disenrolled due to Medicare coverage7Termination of Benefits911Termination of a future-dated linkage14Voluntary Withdrawal912Retro Disenrollment7Termination of Benefits913Cancellation of a Bayou health linkage7Termination of Benefits914Closure of a Bayou health linkage with a valid end of month date7Termination of Benefits915Cancellation due to LaHiPP coverage7Termination of Benefits916Closure due to LaHiPP coverage7Termination of Benefits917Retro-disenrollment of members due to loss of Medicaid or gain of Medicare7Termination of BenefitsAppendix E – Aid CategoriesTable contains the list of the Louisiana Medicaid Aid Categories.Aid CategoryShort DescriptionLong Description1AgedPersons who are age 65 or older.2BlindPersons who meet the SSA definition of blindness.3Families and ChildrenFamilies with minor or unborn children.4DisabledPersons who receive disability-based SSI or who meet SSA defined disability requirements.5Refugee AsstRefugee medical assistance administered by DHH 11/24/2008 retroactive to 10/01/2008. Funded through Title !V of the Immigration and Nationality Act (not the Social Security Act - not Medicaid funds)6OCS Foster CareFoster children and state adoption subsidy children who are directly served by and determined Medicaid eligible by OCS.8IV-E OCS/OYDChildren eligible under Title IV-E (OCS and OYD whose eligibility is determined by OCS using Title IV-E eligibility policy).11Hurricane EvacueesHurricane Katrina Evacuees 13LIFCIndividuals who meet all eligibility requirements for LIFC under the AFDC State Plan in effect 7/16/1996.14Med Asst/AppealIndividuals eligible for state-funded medical benefits as a result of loss of SSI benefits and Medicaid due to a cost-of-living increase in State or local retirement.15OCS/OYD ChildOCS and OYD children whose medical assistance benefits are state-funded. OCS has responsibility for determining eligibility for these cases. These children are not Title XIX Medicaid eligible.16Presumptive EligibleWomen medically verified to be pregnant and presumed eligible for Medicaid CHAMP Pregnant Woman benefits by a Qualified Provider.17QMBPersons who meet the categorical requirement of enrollment in Medicare Part A including conditional enrollment.20TBIndividuals who have been diagnosed as or are suspected of being infected with Tuberculosis.22OCS/OYD (XIX)Includes the following children in the custody of OCS: those whose income and resources are at or below the LIFC standard but are not IV-E eligible because deprivation is not met; those whose income and resources are at or below the standards for Regular MNP; those who meet the standards of CHAMP Child or CHAMP PW; and children aged 18-21 who enter the Young Adult Program.301115 HIFA WaiverLaChoice and LHP40Family PlanningFamily Planning WaiverAppendix F – Language CodesCodes used to identify Language for the Louisiana Medicaid Program.LA CodeDescription834 Code01EnglishEN02SpanishES04ArabicAR19ChineseHY07PersianFA08FrenchFR09GermanDE10GreekEL11Haitian CreoleHT12HindiHI14ItalianIT15JapaneseJA16KhmerKM17KoreanKO18LaoLO20PolishPL21PortuguesePT22RussianRU23SamoanSM24TagalogTL25VietnameseVI26YiddishYIAppendix G – Companion Guide Attribute DefinitionsCodes used to define EDI elementsAttribute DefinitionsRequired AttributeCodeDescriptionMData element is requiredOData element is optionalField Type AttributeCodeDescriptionANAlphanumericIDCode or constant value (i.e. 001=change, 021=add,024=delete)DTDateTMTimeNONumeric OnlyAppendix H – Recipient Header Cross ReferenceNbrFieldBeginEndLenReq?834 LoopNotes/Processing1RECIP-ID-CURRENT11313Y2000 - Member level detail?2RECIP-ID-ORIGINAL142613N?Prior CIN may be the same as current CIN3RECIP-HIC273812N?Medicare SSOC Claim Benefits Number4RECIP-SSN39479Y2100A - Member name?5RECIP-LAST-NAME485912Y2100A - Member name?6RECIP-FIRST-NAME607112Y2100A - Member name?7RECIP-MID-INITIAL72721N2100A - Member name?8RECIP-RECIP-TITLE73753N??9RECIP-RECIP-SUFFIX76783N2100A - Member name?10RECIP-PREVIOUS-LAST-NAME799012N??11RECIP-PREVIOUS-FIRST-NAME9110212N??12RECIP-PREVIOUS-MID-INITIAL1031031N??13RECIP-ADDR-LN110412825N?**No longer used. - Use expanded address14RECIP-ADDR-LN212915325N?**No longer used. - Use expanded address15RECIP-CITY15417118N?**No longer used. - Use expanded address16RECIP-STATE1721732N?**No longer used. - Use expanded address17RECIP-ZIP-CODE1741829N?**No longer used. - Use expanded address18RECIP-BIRTH-DATE1831908Y2100A - Member name?19RECIP-SEX1911911Y2100A - Member name1=M; 2=F; 9=Unknown20RECIP-RACE1921921N??21RECIP-DATE-OF-DEATH1932008N2000 - Member level detail?22RECIP-DATE-OF-CERTIF2012088N??23RECIP-DATE-OF-APPLIC2092168N??24RECIP-DATE-OF-LAST-ACTIVITY2172248N??25RECIP-GROSS-INCOME2252295N?Not needed for EB26RECIP-FAMILY-SIZE2302323N?Not needed for EB27RECIP-SEX-OVERRIDE-IND2332331N?Not needed for EB, used in claims processing28RECIP-EPSDT-TRACKING-INDIC2342341N?Not needed for EB29RECIP-EPSDT-SIGNATURE-DATE2352428N?Not needed for EB30RECIP-DX-DISCHRG-DATE2432508N?Not needed for EB31RECIP-LTC-REVIEW-DATE2512588N?Not needed for EB32RECIP-RECIP-EXCP-IND2592591N?Not needed for EB, used to denote exemption from community care33RECIP-SOURCE-OF-INPUT2602601N?Not needed for EBNbrFieldBeginEndLenReq?834 LoopNotes/Processing34RECIP-TEL-NO26127010N2100A - Member nameData may not be transmitted form Molina35RECIP-PBS-BEG-DATE2712788N?Not needed for EB, used to identify Chisholm-class recipients36RECIP-PBS-END-DATE2792868N?Not needed for EB, used to identify Chisholm-class recipients37RECIP-CASE-MANAGER2872937N?Not needed for EB38RECIP-PID-CARD-NO29430916Y2000 - Member level detail16-digit number in the format 777nnnnnnnnnnnss where n is unique and ss is iterative39RECIP-MOTHER-PERSON-ID31032213N2000 - Member level detail?40RECIP-HOH-LAST-NAME32333412N2100G - Responsible personIf populated, concatenate first name, middle initial and last name and update in ML address attention field.41RECIP-HOH-FIRST-NAME33534612N2100G - Responsible personIf populated, concatenate first name, middle initial and last name and update in ML address attention field.42RECIP-HOH-MIDDLE-INIT3473471N2100G - Responsible personIf populated, concatenate first name, middle initial and last name and update in ML address attention field.43RECIP-HEAD-OF-HOUSEHOLD-SSN3483569N2100G - Responsible person?44RECIP-PREFERRED-LANGUAGE-IN3573582N??4505 RECIP-EXP-ADDR-LN135939335Y2100C - Member mailing Add/update as mailing address4605 RECIP-EXP-ADDR-LN239442835Y2100C - Member mailing Add/update as mailing address4705 RECIP-EXP-ADDR-LN342946335Y2100C - Member mailing Add/update as mailing address4805 RECIP-EXP-CITY46448320Y2100C - Member mailing Add/update as mailing address4905 RECIP-EXP-STATE4844852Y2100C - Member mailing Add/update as mailing address5005 RECIP-EXP-ZIP-CODE4864949N??5105 RECIP-EXP-LAST-NAME49551925N??5205 RECIP-EXP-FIRST-NAME52053920N??5305 RECIP-EXP-MID-INITIAL5405401N??NbrFieldBeginEndLenReq?834 LoopNotes/Processing5405 RECIP-EXP-RECIP-TITLE5415433N??5505 RECIP-EXP-RECIP-SUFFIX5445463N??5605 RECIP-EXTRA-PHONE154755610Y2100A - Member nameAdd/update as state reported phone number 15705 RECIP-EXTRA-PHONE255756610Y2100A - Member nameAdd/update as state reported phone number 25805 RECIP-PHY-ADDRESS-156760135Y2100A - Member nameAdd/update as residential address5905 RECIP-PHY-ADDRESS-260263635Y2100A - Member nameAdd/update as residential address6005 RECIP-PHY-ADDRESS-363767135Y2100A - Member nameAdd/update as residential address6105 RECIP-PHY-CITY-REC267269120Y2100A - Member nameAdd/update as residential address6205 RECIP-PHY-STATE-REC26926932Y2100A - Member nameAdd/update as residential address6305 RECIP-PHY-ZIP-REC26947029Y2100A - Member nameAdd/update as residential address ................
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