130405 0242 Open Issue Tracker - California Health Benefit Exchange

Technical Interface Questions 

track # topic Question Response open / 

closed 

13158 

Please let me know if another meeting is going to be scheduled for the 

benefit and rate guide. Thank you 

13027 6. When does the exchange intend to announce specific dates for when file layouts will 

be finalized and companion guides available? 

Will Covered CA operate in real time or are they sending daily batch file changes in 

13174 834 enrollment? What is the frequency? If a daily transaction, what is the time it will be 

sent? 

13287 834 

13283 

13157 

13033 

13025 

You are sending us an 834 monthly, are we sending you back an 834 or are we 

following up via phone? 

The abortion rider must be billed separately, how is this information going to be 

transferred? Which data field will be used on the 834? 

What will be the procedure to make an enrollment change that creates new effective 

dated rate computation? 

Do embedded dental and vision providers need to be certified by the Exchange to be 

included in the EHB of a full service QHP? 

4 Our understanding is that the exchange will pay agent/broker commissions in the 

SHOP. Are Broker Commissions only applicable for SHOP? Please clarify. 

3-Apr-13 

The companion guides are posted to the bidders library and have been emailed to all technical 

call participants for whom I have contact information as part of the meeting materials when the 

topic of the meeting is that particular guide book. 

closed 

closed 

834 transactions will be sent daily. Time of day is not yet determined. closed 

834 will be transmitted daily - reconciliation will be done monthly. closed 

A rider is not a QHP. 

All effectuation date changes will be initiated in Covered CA (CC) - CC will have rules for any rate 

changes. 

All questions regarding solicitations need to be communicated as outlined in the solicitation 

process. 

ANSWER - Covered California will pay agents, general agents and secondary agents in the 

SHOP market only for those agents who are contracted to participate in the SHOP market. This 

SHOP Agent contract will allow these agents to interact with all SHOP QHP Issuers and all SHOP 

Employers, unilaterally standardizing agent commissions and performance structure. 

13036 SERFF Are SHOP brokers included in the SERFF template/module? Broker information is transmitted in the 834 transaction files. closed 

13093 

13032 

834 

Please clarify the broker information that will be sent in the 834 and the report you will 

send with the applications. Also clarify how non-paid sister entities will be reported. 

How will CC identify PCPs through this provider data file? Could they simply add a 

data element of PCP – 1 char – Y or N? 

13030 Is the HIX file sent in by Athena correct? Please validate 

business process question not 834 question. On 834 broker info will be sent (1000cn1 and 

1000act) 

CalHEERS doesn‟t need identification of PCPS for any enrollment. However, a PCP is field is 

provided in the Provider Directory field. 

corrected HIX file sent back in reply with corrections highlighted in yellow (NOTE FOR 

CONTRACTORS - A HIX file is being prepared for distribution to the group and should be 

available week of 8 April) 

13024 

3.B. How will that information be sent/received between the exchange and the 

carrier? 

Covered CA is planning on sending an agent identifier on the 834 that we send to the Carrier. closed 

In reading the draft Companion Guide, on page 12 it mentions that the enrollee‟s SSN 

is transmitted in the NM1 segment on the initial enrollment transactions, but is not Covered California (CC) will follow CMS guideline and only send SSN on the initial. CC uses the 

13028 

included in maintenance transactions between the FFE and Issuer. Is this true? Since Exchange Assigned Member ID and Issuer Assigned Member IDs (both would be sent) in all closed 

the SSN is the main identifier for enrollees, I would hope to receive the SSN on all other transactions (updates, disenrollments). 

transactions for the member. 

13023 

3.A. Our understanding is that carriers are to pay any agent/broker commissions in 

the individual market. 

Covered California will not pay agents or general agents in the Individual market. 

closed 

13192 test strategy Will there be another meeting to discuss the Testing Plan and Benefit Data Currently scheduled for 11 April - Go-To meeting info will be sent out 5 April closed 

13225 provider dir 

13106 

13040 

834 

834 

Provider question: I know you have indicated a quarterly batch file for provider 

directory. If we send files more often, will you update the information more often? If 

not, are you willing to consider going back to the monthly frequency initially discussed? 

8.6. CHANGE IN CIRCUMSTANCE – SHOP ONLY - Can you explain what this 

means? 

On the call yesterday, there was one person who mentioned that a group file would be 

sent with all the employer data we need for SHOP members. Can you confirm this? 

I‟ve heard about this group file on the calls that CMS was having for the FFE 834 but 

not in the CC arena 

Currently this will happen quarterly. Consideration for update frequency can be discussed in the 

future. 

following CMS companion guide - OLIVER TO POST CMS COMPANION GUIDE TO BIDDERS 

LIBRARY AND SEND OUT TO ALL TECH CONTACTS 

group setup - there will be another companion guide for group setup. The Group Setup Guide is 

due to be posted to the bidder's library 23 April with a technical call for that date on 30 April. 

closed 

closed 

closed 

closed 

closed 

closed 

closed 

closed 

closed 

closed 

130405 0242 Open Issue Tracker 1 14 4/5/2013



closed 

13190 test strategy 

The presenter has discussed the testing of the 834/820 transactions. What about other 

transactions such as group setup and provider files? 



834 and 820 data will be needed for testing 3 June. 

Provider files will be needed by first stage testers by 15 April. Provider files by 2nd stage testers 

will be required by 3 June. 

closed 

13200 

We were told at one point the Group Setup file would be sent separately and in 

advance. Are you now saying groups will be in the 834. 


due to be posted to the bidder's library 23 April with a technical call for that topic on 30 April. 

834 and 820 data will be needed for testing 3 June 

13202 please email links to bidder‟s library http://www.healthexchange.ca.gov/Solicitations/Pages/QHPSolicitation.aspx closed 

13227 URL please post the bidder library URL http://www.healthexchange.ca.gov/Solicitations/Pages/QHPSolicitation.aspx closed 

13203 

1. When will the SERFF Plan Management Module for California be available? It is 

available now. 

http://www.serff.com/# 

closed 

13196 SERFF 

please post instructions on how to get onto SERFF? 

http://www.serff.com/# 

http://www.serff.com/plan_management_data_templates.htm 

SERFF training is available on this website 

closed 

13088 

13097 

834 

834 

13047 834 

If a dependent is added will this be considered a change in coverage? Will this require 

a termination & add as described in section 8.5 even? 

if adding it is not a termination and add it is a trans to add only 

Could you please clarify rules you use to determine the subscriber in a family - (Oldest In a house hold, the person who is filling out the application is a person getting insurance they will 

family member is "made" subscriber)? 

be subscriber otherwise oldest is default 

The companion guide states that Covered California will send a monthly 834 and the 

In answer to her question – the reporting of errors on the 834 is a manual process 

QHP will use that to reconcile in their system. It then states that the QHP will report an 

discrepancies to Covered California. However, it doesn‟t state how the QHP is 

I would double check with the technical folks as I do believe that there are some established 834 

reporting the discrepancies? Are we sending an additional 834 back to Covered 

reportable transmission errors that exist in this process as well. 

California or is it a manual process? 

13305 834 1. Please confirm that a member will always have a unique CC assigned member ID. In the individual market all members are assigned a unique member ID closed 

13301 

2. Will a member's APTC be determined on a monthly basis or during initial enrollment 

initial and redetermination only. 

and any redetermination. 

closed 

13102 

On enrollment effectuation - should the Maintenance Type Code for 2000 INS03 be 

834 021? looking for CMS to provide guideline 

closed 

13095 834 Can you please add the DMG segment and elements used to the companion guide? newer version has that in it closed 

13199 Will all carriers be invited to the meetings with the testers? no closed 


Has CALHEERS decided to add the PCP selection if the member in the 834 feed to the No PCP data will be sent. The system is not designed to allow PCP selection during the 

carrier?Load? We are interesting in getting the timing, what to submit and how. enrollment process. 

closed 

closed 

closed 

closed 

closed 

13105 

834 

13317 SERFF 

13100 

834 

13045 SERFF 

In 8.4 SHOP Market Re-enrollment - Will reinstatements never occur? 

Reinstatements with or without a lapse, members canceled in error, etc? Would a new 

QHP member ID need to be generated? If so will the exchange be able to handle this? no reinstatements in SHOP 

It is my understanding there are fees associated with serff submissions, will we need to Rates are required to be submitted to regulators via SERFF. More information is available on the 

pay fees for the test data submission? 

SERFF website. The SERFF link is: http://www.serff.com/# 

On enrollment effectuation - Will the QTY totals represent what was sent on inbound or 

actual totals computed from the membership being sent on the outbound? 

reflect on what we sent to them (inbound) 

templates are not final until 29 March - can we have a later date for the test data in 

see # 13044 

SERFF template format to be due and if so what date? 

closed 

closed 

closed 

closed 




closed 

13042 SERFF 

What is the deadline for uploading the templates to SERFF? 

1. Administrative template 

2. Plan rates and benefit template 

3. Service area template 

4. Network template 


templates previously communicated? 

See # 13044 for test strategy. All test data will be provided to CALHEERS via excel files. DO 

NOT UPLOAD TEST DATA TO THE SERFF WEBSITE. 

13197 please update the posted plan tech sched and the test strategy see # 131195 answer closed 

13194 

Connectivity date Test Plans and Test cases availability... Testing will start when for 

test strategy 

the 2 Carriers... Other Carriers will start when? 

see # 13195 

closed 

Based on the 834 Companion Guides, the Exchanges will be sending a member's 

responsible SR amount in dollars instead of a percentage. It seems it will be difficult, if 

13312 834 

not impossible, to determine copay amounts from a specific dollar amount. Since CSR 

see answer to # 130046 

applies to copays, we need to know how the Exchanges expect carriers to determine 

closed 

the different copay amounts from he information provided in the 834. Is it possible for 

the Exchanges to calculate CSR and send percentage instead? 

Clarification on the 4/15 test data date: for those bidders that are selected for the first 

round of testing, are you expecting anything in addition to the Plan/Network/Rate serff 

closed 

13038 SERFF 

When we try to open the hyperlink or attach the url to the internet browser in the 

DRAFT Plan Benefit and Rate Implementation Guide we receive an error message (the 

file does not exist).We are trying to view these templates and I can‟t seem to locate 

them through the SERFF website either, can you assist? 

see test strategy already answered above. All test data templates will be listed in the ITD (this list 

will be filled in here 8 April) 

SERFF has updated their links - we are updating the guide books with the current links now. 

They will be resent to all bidders. With each updated version of the guide books the links will be 

tested to ensure they work at the time the guide is posted. 

Testing with issuers will follow a two stage process. 

The first stage testing will include three issuers and will focus on confirming that the CalHEERS 

application correctly generates the outbound transactions and correctly processes the issuer‟s 

response. CalHEERS is scheduled to begin the coordination and planning activities with the 

three issuers in April. Test cases will be supplied to all issuers during the planning process. 

Connectivity testing is expected to occur mid to late May. 

• Only the 3 first stage test issuers need to provide representative test data on 15 April. No 

other bidders need to provide test data in April or May. 

CLOSED 

closed 

13044 test strategy Is the test data still due on 1 April? (which is a holiday) 

• First stage testing kick off meetings will happen with each of the 3 chosen initial test issuers 

as soon as can be scheduled. Attendance will be technical personnel as identified by each side. 

Each meeting will be one on one between CalHEERS and issuers. 

• Transactional testing between the three issuers and CalHEERS is scheduled to begin mid- 

May and run through July. 

• Testing in June and July will utilize test data submitted by the first stage testing issuers on 

April 15 as well as the test data required from the rest of the issuers on June 3rd. 

The second stage of testing will include the remaining issuers and will focus on certifying that 

each issuer can process inbound transactions and generate appropriate responses. A 

CalHEERS testing resource will work with an issuer to identify an individual testing window. Test 

cases utilized during the first phase will be repurposed for certification testing. Certification 

testing is expected to begin on July 22 and continue through September 6. 

closed 

13195 test strategy please post the test strategy see answer to # 13044 closed 


2. For the April 1 st Plan Management Data test, where is this data submitted? The 

chosen first stage test parties will be identified and contacted with all required 

information and dates. 


closed 




closed 



13313 834 


We do not have SERFF access yet, though we started the process weeks ago – we 

have been calling SERFF and they have not responded, except to say they would get 

back to us on April 3d. This will hinder us getting the TESTING templates to you via 

SERFF by April 1. We need an extension to the April 1 deadline to submit test data for see answer to # 13044 

this reason. Alternatively, we are planning to load the plan, benefit and rate test data in 

the templates and then email them directly to you by April 1. Please let us know ASAP 

whether or not this will work for you. 

I was a bit confused on the call yesterday. If I am correct, there will be test files given to 

CalHEERS on April 15th by 2-4 issuers using mock-up data. And the larger group will 

submit files sometime in July. 

Does this mean that the Provider Directory is no longer due to the Exchange June 1st? 

Do the benefit designs in each region have any relationship to our “service area” 

template (is service area based solely on the areas in which the plan is licensed?) 

I just want to verify that I am understanding the test strategy. In yesterday's meeting, 

the testing for the 834 & 820 transactions will be with 2 carriers. 

Then there was some discussion about the test data for the plan load, etc. which was 

originally due 4/1. Is this phase also going to be with the 2 carriers chosen? Is the 4/1 

due date for plan, benefit, and provider pushed out? Or should we be panicking to hit 

that 4/1 date? It sounded like we have a reprieve. Please advise. Thanks. 




closed 

closed 

closed 

closed 

13139 834 

CMS published a document with 834 scenarios (see attach) can we get sample 

transactions for all these scenarios? 

The 834 guide is posted in the bidder's library. CMS is due to release some updated information 

that will require us to update our 834 guide. The CMS information is due out any day now, so we 

want to have the follow-on 834 call after they give us their update and we have updated our guide 

books to reflect that information. We are planning on the next 834 call to happen on 25 April. 

closed 

13201 please post the material from the 834 call 

13046 834 

Based on the 834 Guide CC will be sending a member's responsible CSR amount in $ 

instead of a %. It seems difficult if not impossible to determine copay amounts from a 

specific dollar amount. 

Since CSR applies to copays, issuers need to know how CC expects issuers to 

determine the different copay amounts from the information on the 834. 

Is it possible for CC to calculate CSR and send a percentage instead? 

The 834 guide is posted in the bidder's library. CMS is due to release some updated information 

that will require us to update our 834 guide. The CMS information is due out any day now, so we 

want to have the follow-on 834 call after they give us their update and we have updated our guide 

books to reflect that information. We are planning on the next 834 call to happen on 25 April. 

The CSR amount represents the CMS approved PMPM ESTIMATE to be advanced to 

contractors. The contractors are responsible for submitting to CMS their ESTIMATE PMPM for 

approval. 

13282 What are premium paid dates, the date a premium was paid or paid through? The date the premium is paid. closed 

The Exchange (COVERED CALIFORNIA) will be the point of contact to update /change 

2 Can an enrollee change e.g. their demographic data, add dependents etc. by 

13022 

members‟ information. As a result the info will then flow to the carriers and both systems will stay closed 

contacting their plans, or do they have to contact the Exchange directly? 

true. 

13021 1 For individual members, what changes will/can be made by the carriers? 

13304 SERFF 

13034 

Will links/templates in the Draft Plan Benefit and Rate Implementation Guide be 

updated to include the most recent CMS 3/27/13 template updates for the three QHP 

templates – Prescription Drug Template, Rate Tables Template, and Plan & Benefits 

Add-In Template to fix defects found during testing? 

The Exchange (COVERED CALIFORNIA) will update members‟ information and as a result it will 

get uploaded to carriers. This way both systems stay true. 

The links and the screen views to the templates in the Guides will be tested and updated with 

each guide update. Changes to the templates themselves is not in Covered CA or CALHEERS 

control but any errors found during testing will be relayed to CMS. 

Yesterday in the tech meeting, there was mention at the very end of the meeting that 

the embedded pediatric dental and vision providers will need to be included in the 

The provider directory is per issuer. Any Provider for which the plan includes within their network 

Provider Directory. Can they verify that this is correct and that it will not be a separate 

should be included. 

directory? Do any acupuncture providers also need to be included? We are required to 

cover medically necessary acupuncture per the benchmark plan. 

closed 

closed 

closed 

closed 

closed 




closed 



Will the Exchange use a standard directory format, or will there be the flexibility to 

accommodate the PPG configuration. contractor HMO directories list the PPG and 

hospitals and PCPs affiliated with the PPGs 

The provider directory data is due to the Exchange on 06/01/13. Will contractor have 

an opportunity to update the data before the Fall Open Enrollment? Will health plans 

be able to submit directory files on a monthly basis? 

3. On the Networks template, what is the URL that is being requested? this should 

be your organization's provider network URL. 

The Provider directory is submitted for testing (and later upload to CALHEERS) in the SERFF 

format. The Draft Provider Directory Guide is posted in the bidder's library. An updated version 

will be posted soon, but the edits to the update do not have any changes to content. 

Live Provider Directory information uploaded to CALHEERS will be updated quarterly. 

The URL that links to the contractors provider search 

closed 

closed 

13090 

they were released in oct 2012 so they need to update and as soon as they do we will distribute. 

CMS is due to release some updated information that will require us to update our 834 guide. 

The CMS information is due out any day now, so we want to have the follow-on 834 call after they 

closed 

834 

CMS published a document with 834 scenarios (see attach) can we get sample 

transactions for all these scenarios? 

give us their update and we have updated our guide books to reflect that information. We are 

planning on the next 834 call to happen on 25 April. 

While the NPI is a required element, we do not have it for all providers: providers who 

13253 

do not bill Medicare are not motivated to provide it. Therefore it will be blank for some This field cannot be blank. The data will error if missing NPI 

closed 

providers. How do we handle this currently required field given this reality? 


Under what circumstances will “FFS Provider” (#50) and “FFS Provider County” (#51) 

be required to be completed? 

this is for Medi-Cal only 

closed 

13243 provider dir What is a network tier ID? 

This is only applicable if you are offering 2-tier network plans. If you do not have 2-tier networks 

then this field is not applicable to you. 

closed 

13236 provider dir We have a network ID but not the Tier Tier is not required closed 

13259 

Can we get the provider taxonomy list you plan on using (or let us know when it will be Updated taxonomy will be available soon(and shared as soon as available) - but for now use the 

available)? 

taxonomy codes you normally use. 

closed 

13039 SERFF 

The feds have been posting updated templates 

(http://www.serff.com/draft_plan_management_data_templates.htm) 

and conducting trainings (attached) Do you have any idea whether CA Exchange will 

use the federal plan management templates or will be using their own? In other words, 

is Covered California is expecting plans to participate in these trainings and use these 

templates designed for the Federal Exchange and State Partnership Exchanges? 

We are using these templates as well as the SERFF Plan Management module. 

PLEASE attend the training you find pertinent in this flyer. It will help you as we move forward 

with our calls and discussions. 

13228 provider dir when will the provider directory be updated? 

We will post an updated provider directory, however, current edits do not include changes to 

current content. 

closed 

13103 

On enrollment effectuation - in 2700 do we need to send back whatever is sent on 

834 inbound? Flow diagram needed. 

what was sent as inbound needs to be sent back. 

closed 

13084 

Need confirmation that multiple Groups/Sponsors will be represented in a single 834. 

834 Can the 834s be grouped by Sponsor? (SHOP only) 

whatever info has changed in system GetInsured (GI) will create 1 for each carrier and individual 

closed 

13043 SERFF Is the test data supposed to be provided in SERFF template form? yes closed 

13098 834 Will the state require TA1 on files that are good? yes closed 

13175 Will contractor have view access into Covered CA's website for pending enrollments? Yes closed 

13176 

Is the Exchange the system of truth for all changes? What about items that impact 

eligibility vs. items that do not have an eligibility impact? 

Yes - Covered CA(CC)/Exchange is the system of record 

closed 

13165 

If a person re-ages during the plan year, will a rate change need to be held off until the Yes - rate base - Rate is based on age @ enrollment. It does not change until next enrollment 

next plan year or is a change allowable mid-plan year? 

year. 

closed 

13031 

Please confirm that the provider data submitted by a full service QHP should include Yes for the purposes of loading into CalHEERS the single directory file as provided in Provider 

the embedded behavioral health, dental and vision providers. 

Directory Guide will include behavioral health, dental and vision providers. 

closed 

13198 Is it possible for the carriers to obtain copies of the test scenarios? yes they will be shared with the full group of technical call participants closed 

closed 




closed 

13026 

4 March - Right now all transactiosn are expected to be processed within 24 hours. However, 

5. When will SLAs be shared with carriers for transaction TATs etc. 

not sure what is meant by “time to complete an enrollment”. If this is in relation to sending the 

CLARIFICATION 21 Feb - When will the service level agreements be published 

834 transaction, then the 24 hour timeframe is expected. If it means the time to send a health 

specifying the turnaround times for all transactions. For example, what is the maximum 

plan card and packet, then (Enrollment and Eligibility) Thien will need to provide that answer. 

time an enrollment transaction must be acknowledged? And what is the maximum time 

to complete an enrollment. 

open 

13110 

13096 

13085 

834 

834 

13081 834 

13086 

13037 

13180 

13091 

If data errors in 834, how do we communicate the issue (e.g., DOB 1/1/1900)? How do 

we correct it? 

Current practice: phone call. Possible: outbound 834 with error code (2100 loops). 

Could you be specific on all scenarios where broker information will be sent in the 834 

and the report you will send with the applications? Also clarify how non-paid sister 

entities will be reported. 

Discrepancy and reconciliation reports are being developed. More information will be coming on 

these. 

follow up ask what the second question is 

834 If we will receive contractor generated group id or exchange assigned group id on 834? follow up with asker - we need more clarification to answer this question. 

Can we get a Trading Partner Companion guide with all the communication protocols, 

delimiters, actual Identifiers for ISA06 & GS02, file handling instructions, file naming 

conventions for SHOP/IFP, expected frequencies of in-bound/out-bound transactions 

and troubleshooting instructions? 

834 

trader 

partner 

agreement 

834 

Is SHOP exchange expecting contractor to generate unique group id per plan the group 

is enrolled in. (This requirement is called out in SHOP group setup document CMS had 

sent)? 

The draft implementation guides released last week state that CalHEERS will require a 

signed Trading Partner Agreement before directory testing starts 4/1/13. Can you 

please provide additional information about this agreement? 





more information will be available shortly 

Is COCC supported on the Exchange? Does the carrier need to produce the COCC for 

Need clarification - what is COCC? 

on-Exchange members or will the Exchange be handling that? 

Can we get a sample file with an example of how multiple ST-SE envelopes will be 

used? 

sure 

13191 820 When will the 820 Implementation Guide be available, and when will that testing occur? the 820 test data will be needed in June. open 

13107 

13172 

834 

9. MONTHLY RECONCILIATION - Says "QHP Issuers will reconcile this information 

with their systems and report any discrepancies to Covered California." What are the 

remediation steps that need to occur for discrepancies sent back to the exchange? 

Will the discrepancies come back on an 834 or report? If report can you define the 

report format? 

At what point will Covered California determine what they will need from contractor to 

be ready for 7/1 go live date? Are there any additional marketing materials required in 

addition to plans and rates? 

This is a combination technical and business process question. We will provide more information 

soon on this. 

This is not a technical question. I will forward to the right folks. CalHEERS will need some 

brochure data - but marketing material requirements will be communicated by the marketing 

team. 

open 

open 

open 

open 

open 

open 

open 

open 

open 

open 




closed 

We don‟t have information to answer the Formulary Template question at this time. 

We will provide information as soon as we have an update on that SERFF template. 

Please see the available test strategy information below: 

Testing with issuers will follow a two stage process. 

The first stage testing will include three issuers and will focus on confirming that the CalHEERS 

application correctly generates the outbound transactions and correctly processes the issuer‟s 

response. CalHEERS is scheduled to begin the coordination and planning activities with the 

three issuers in April. Test cases will be supplied to all issuers during the planning process. 

Connectivity testing is expected to occur mid to late May. 

• Only the 3 first stage test issuers need to provide representative test data on 15 April. No 

other bidders need to provide test data in April or May. 

13035 test strategy Are the templates that are due 4/1 to include the completion of the Rx template? 

• First stage testing kick off meetings will happen with each of the 3 chosen initial test issuers 

as soon as can be scheduled. Attendance will be technical personnel as identified by each side. 

Each meeting will be one on one between CalHEERS and issuers. 

• Transactional testing between the three issuers and CalHEERS is scheduled to begin mid- 

May and run through July. 

• Testing in June and July will utilize test data submitted by the first stage testing issuers on 

April 15 as well as the test data required from the rest of the issuers on June 3rd. 

The second stage of testing will include the remaining issuers and will focus on certifying that 

each issuer can process inbound transactions and generate appropriate responses. A 

CalHEERS testing resource will work with an issuer to identify an individual testing window. Test 

cases utilized during the first phase will be repurposed for certification testing. Certification 

testing is expected to begin on July 22 and continue through September 6. 

open 

13109 

13094 

13082 

834 

834 

834 

What will be the procedure to make an enrollment change that creates new effective 

dated rate computation? 

In the 2000 member loop Subscriber number can you identify that the qualifier 0F is 

used in REF01 of the HIX companion guide table? 

There was a comment re: "a whole bunch of ST/SE's on the response back to the 

Exchange". Was this re: 834 confirmation or TA1/999? What frequency would they 

want these bundled (daily/hourly.etc.)? 

we need more clarity on this question - please send more information on the question. 

We will follow up and get back with answer 

We will follow up with complete answer asap. 

13087 

834 If a dependent is added will the subscriber be carried as a passive loop in the 834? We will follow up with complete answer asap. 

open 

13089 

Can we get sample 834 transaction files for each enrollment scenario in section 7 of 

834 the companion guide? 

yes 

open 

13119 834 FFE 834: SSN only on initial 834. Exchange's planned practice? Yes for the individual market. We will check for SHOP and follow up to this response. open 

13101 

On enrollment effectuation - in the 2000 REF01/REF02 Will you need to also include 

834 17 and 0F? yes on 17 and on 0F GI will follow up 

open 

13173 834 What is the Exchange SLA's on enrollment changes? open 

13177 

Do you have a matrix of all changes that will go through the Exchange (e.g. life 

changes)? How will these changes be communicated (all through the 834)? 

open 

13182 834 

Is the only agent/broker information captured on the consumer enrollment application, 

and 834, the broker name and broker account information? 

open 

13099 

On enrollment effectuation - Is the expectation that we would store the value sent in the 

834 BGN02 and send that same value back on the outbound? 

follow up 

open 

open 

open 




closed 

13121 834 Will SHOP and IFP use the same monthly reconciliation method for members? 

13133 834 

13257 

13104 

834 

Can we get a Trading Partner Companion guide with all the 

communication protocols, delimiters, 

actual Identifiers for ISA06 & GS02, 

file handling instructions, 

file naming conventions for SHOP/IFP, 

expected frequencies of in-bound/out-bound transactions and 

troubleshooting instructions? 

Wanted to follow-up on this question. Will all the data submitted by the plan be 

included in the physicians' or facility data. Can you provide the format the data will 

appear in. 

In 8.3 Individual Market Re-enrollment - What will the INS03 code be? No INS03 is in 

the CG should it be 025 - Reinstatement? 



The trading partner agreement will be available prior to any connectivity testing. 

we need more clarity on this question - please send more information on the question. 

we will follow up 

13080 834 

Can we get a flow description of identifiers inbound/outbound with diagrams in the 

companion guide or separate document of the Trading partner IDs, BGN02/BGN06, 

Header REF02, QTY, Group IDs, Plan IDs, 2700/2750? We would like it to be similar 

to the "834 Identifiers Discussion Document" prepared by CMS for the FFE? 

13083 834 

Exchange expects single 999 for transmission. By definition 999's are at GS/GE level, 

does this assume they'll have one GS/GE per transmission? 

13092 834 

Currently contractor utilizes ST02 (transaction control set number) as unique group 

identifier sent in ST header loop for compare purposes. Will HIX use the ST02 

information to define each unique group? A HIX sample file would help to show how 

multiple groups in an 834 will sent and identified? 

13111 834 We assume we will receive Individual Market and SHOP 820s at the subscriber level 

13112 834 

Confirm subscriber level 820 files from SHOP will be received daily? If not, expected 

frequency. If we don't see a file when expected, is it an error? Note that empty files 

files are a bad thing. 

13113 834 

Will we see an 820 for EFT for aggregated premium payment? If so, how do we 

identify? 

13114 834 Will we see EINs in Individual Market 834s? 

13115 834 

Assume exactly 3 files per day inbound to Issuer: 

1) IFP 834 

2) SHOP 834 

3) SHOP 820 

contractor will not look for multiple files in these areas 

13116 834 

Assume exactly 3 files per day outbound from Issuer to Exchange: 

1) IFP 834 

2) SHOP 834 

3) IFP 820 

13117 834 

13118 834 

13120 834 

FFE plans to have unique Member ID in SHOP but we understand CA plans to use 

SSN in SHOP, CIN in IFP. Due to limitations on SSN as identifier, is this still planned? 

Verify will receive both SSN and CIN for IFP. 

Latest was SSN would be the ID for SHOP, but FFE is avoiding, sending only on first 

enrollment 834. Will CA also create a unique person ID for SHOP? 

SSN is required for IRS reporting for minimimum essential coverage. 

We assume that all employee must have SSNs, so we will always receive SSNs for 

subscribers 




closed 

13122 834 

If CA contracts out SHOP, then will we use that vendor's EDI/reconciliation or will EDI 

remain on the Exchange platform per Exchange protocols? 

13123 834 

Options for member reconciliation: 

Full file (stated in earlier discussions) - Complete roster, we act on discrepancies 

(enroll/autoterm to synchronize) 

Audit file - Generate report of discrepancies, then Exchange indicates actions to take 

on subsequent communication 

Audit file is our preferred course of action for optimal customer experience 

13124 834 

If discrepancies in membership reconciliation, we report on discrepancies. 

Do you review, confirm prior to our resynch? 

How do we resynch? Do we accept and enroll/terminate to synchronize? 

Terminate if not on your file? Normally we confirm first - ensure not error omit 

How handle timing asynchrony? Will Exchange freeze updates on a reconciliation 

cycle? 

How manage member impacts? 

13125 834 

Which elements will be reconciled (i.e., Exchange System of Record and customer 

must return to Exchange to update) 

Assume minimally 

Eligibility: Legal Name, Residency Address, DOB 

Identifiers: CIN, SSN 

Issuer controlled, not reliable for Member to change by contacting Exchange: 

Issuer ID 

Optional info Member may wish to vary across systems, keep private 

Preferred Name 

Preferred Contact: Current phone, current e-mail 

Billing info: Current billing address and/or e-payment account, 

third party payer name/address/contact, etc. 

Other Info that may change (e.g., agent transfers book of business) 

Broker/Agent (will impact our compensation of broker) 

13126 834 

Confirm that the HIX Group ID field is our Group ID passed back in response to XML 

SG Setup; we also receive EIN in its own field? 

Is Group ID required to be HIOS/SERFF ID? If ID changes at renewal, how do we 

update Exchange? 

13127 834 Will we get renewal 834 transaction for employee during open enrollment? 

13128 834 

Would like Producer (Agent, Broker, etc.) ID for all Individuals/Employers assisted; 

Exchange itself may be the "producer" or "agent" 

13129 834 There are both US and CA EINs; will we receive both? Where? 

13130 834 Confirm CA will follow CMS in using the Exchange compatible 820 

13131 834 

Will we receive renewal transactions for members who 

actively or 

passively 

choose to stay with their current plan? 

13132 834 

Can we get a flow description of identifiers inbound/outbound with diagrams in the 

companion guide or separate document of the Trading partner IDs, BGN02/BGN06, 

Header REF02, QTY, Group IDs, Plan IDs, 2700/2750? 

We would like it to be similar to the "834 Identifiers Discussion Document" prepared by 

CMS for the FFE? 

13134 834 

There was a comment re: "a whole bunch of ST/SE's on the response back to the 

Exchange". Was this re: 834 confirmation or TA1/999? What frequency would they 

want these bundled (daily/hourly.etc.)? 




closed 

13135 834 

Exchange expects single 999 for transmission. By definition 999's are at GS/GE level, 

does this assume they'll have one GS/GE per transmission? 

13136 834 

Need confirmation that multiple Groups/Sponsors will be represented in a single 834. 

Can the 834s be grouped by Sponsor? (SHOP only) 

13137 834 If a dependent is added will the subscriber be carried as a passive loop in the 834? 

13138 834 

Can we get sample 834 transaction files for each enrollment scenario in section 7 of 

the companion guide? 

13140 834 

Can we get a sample file with an example of how multiple ST-SE envelopes will be 

used? 

13141 834 

Currently contractor utilizes ST02 (transaction control set number) as unique group 

identifier sent in ST header loop for compare purposes. Will HIX use the ST02 

information to define each unique group? A HIX sample file would help to show how 

multiple groups in an 834 will sent and identified? 

13142 834 

Please clarify the broker information that will be sent in the 834 and the report you will 

send with the applications. Also clarify how non-paid sister entities will be reported. 

13143 834 

In the 2000 member loop Subscriber number can you identify that the qualifier 0F is 

used in REF01 of the HIX companion guide table? 

13144 834 Can you please add the DMG segment and elements used to the companion guide? 

13145 834 

Could you be specific on all scenarios where broker information will be sent in the 834 

and the report you will send with the applications? Also clarify how non-paid sister 

entities will be reported. 

13146 834 Will the state require TA1 on files that are good? 

13147 834 

On enrollment effectuation - Is the expectation that we would store the value sent in the 

BGN02 and send that same value back on the outbound? 

13148 834 

On enrollment effectuation - Will the QTY totals represent what was sent on inbound or 

actual totals computed from the membership being sent on the outbound? 

13149 834 

On enrollment effectuation - in the 2000 REF01/REF02 Will you need to also include 

17 and 0F? 

13150 834 

On enrollment effectuation - should the Maintenance Type Code for 2000 INS03 be 

021? 

13151 834 

On enrollment effectuation - in 2700 do we need to send back whatever is sent on 

inbound? Flow diagram needed. 

13152 834 

In 8.3 Individual Market Re-enrollment - What will the INS03 code be? No INS03 is in 

the CG should it be 025 - Reinstatement? 

13153 834 

13154 834 

13155 834 

13156 834 

13187 

In 8.4 SHOP Market Re-enrollment - Will reinstatements never occur? 

Reinstatements with or without a lapse, members canceled in error, etc? Would a new 

QHP member ID need to be generated? If so will the exchange be able to handle this? 

8.6. CHANGE IN CIRCUMSTANCE – SHOP ONLY - Can you explain what this 

means? 

9. MONTHLY RECONCILIATION - Says "QHP Issuers will reconcile this information 

with their systems and report any discrepancies to Covered California." What are the 

remediation steps that need to occur for discrepancies sent back to the exchange? 

Will the discrepancies come back on an 834 or report? If report can you define the 

report format? 

Which dates will be sent for benefit changes - effective date will be the following day to 

the termination? 

provider directory: 

1) Define a provider labeled „D‟ for Dental. Just those with a DDS or DMD 

degree? 




closed 

provider directory: 2) Define provider labeled „V‟ for Vision. Only those with a 

13188 

degree in Optometry (OD)? Which other degrees or specialties within MD should be 

considered as „V‟? 

general question When will be the RFP award announced as Carrier need to know 


when they can involve in testing with CA Exchange ? 

13206 

4. Regarding the Contacts on the Administrative Data Template: 

a. What is the definition of the „User Access‟ contact? The person in the issuer 

organization who defines their user roles and responsibilities. 

b. What is the definition of the „APTC/CSR‟ contact? The person who is the 

organization SME for APTC/CSR. 

c. We are partnering with a dental plan for dental benefits. Who, if anyone, should 

be indicated for the Dental Director? all dental providers should be in your directory - 

each plan ID will have 1 directory. 

d. Is the Pharmacy Benefit Manager contact somewhat within our organization or 

someone at our contracted pharmacy? within your organization. 

e. If we are not using the On-line Enrollment Center, should the primary and backup 

contacts be blank? They can be blank. 

13207 provider dir Clarify Facility Type usage; Is there also going to a Provider type. 

13208 provider dir Date Created - how used and is it a constant for the file? 

13209 provider dir Date updated - how is this used? 

13210 provider dir How is a null sent - with two adjacent commas 

13211 provider dir What are the file rejection criteria. 

13212 provider dir What edits are needed for 'bad data' - eg. Alpha in an SSN. 

13213 provider dir Method to send file and file format. Explain more about the FTP destination 


While the NPI is a required element, we do not have it for all providers: providers who 

do not bill Medicare are not motivated to provide it. Therefore it will be blank for some 

providers. 

13215 provider dir How do we handle this currently required field given this reality? 

13216 provider dir Item #4: How is the network ID generated? 

13217 provider dir Item #5: Under what circumstances is this field required to be completed? 

13218 provider dir Item #21: When will the list of taxonomy codes be made available? 


Item #27: Is the expectation that plans will include providers who are retired, deceased 

or inactive on their files? We are assuming that we will be sending full files of active 

providers only. 


Item #30: How should plans indicate on the file if a provider is contracted with more 

than one medical group? 


Item #31: How should plans indicate on the file if a provider has more than one 

hospital affiliation? 


Item #50 and 51: Under what circumstances are these fields required to be completed? 

When will the Trading Partner Agreement be released? 


Certain Specialties are going to be displayed or are we adding all specialties that we 

post in our current hard copy directories 

13224 834 Specialty Code? What is the Specialty Code? 

13226 

trader 

partner When will the trader partner agreement be available? 

agreement 

13229 provider dir Is Date Created the system run date? 




closed 


Is Date Last Updated in regards to any provider field that has changed from the 

previous version? 


Is Data Source the health plan? Does CA HIX have a specific value they want us to 

use? 


Will CA HIX require Hard Copy Directories? If they do, when are they required? 

During the certification period? Please explain how this is used and assigned again. 

13237 SERFF You mentioned that the SERFF document would assign this code, is that correct? 


Provider Type indicator - If specialty code will determine it, What specialties qualify for 

'D' and 'V'? It says situational - so it is required for providers? 


Is there any flexibility with the field lengths? This is an issue for contractor as our 

internal provider ids are up to 16 characters long? This is related to the PCP ID and 

Location IDs. 


Also, give a little more info on the “location ID”. A site (site id) is used by multiple PCPs 

in contractor system. That site id is also 16 characters long in our system. 


Under what circumstances are Items #50 and 51 these fields required to be 

completed? 


The provider directory data is due to the Exchange on 6/1/13. Will Health Plans have 

an opportunity to update the data before the Fall open enrollment? 


Accessibility Codes field is Varchar(1). How should this be listed when there are 6 

different accessibility codes? 

13246 

What format will the physician data appear in the directory. Can health plans include 

the physicians physician group affiliations to include with the physicians' names? 

13247 provider dir Clarify Facility Type usage; Is there also going to a Provider type? 

13248 

Date updated - how is this used – is it when data changed from a previous quarter for a 

provider? 

13249 How is a null sent - with two adjacent commas? 

13250 What are the file rejection criteria? 

13251 What edits are needed for 'bad data' - eg. Alpha in an SSN? 

13252 

Method to send file and file format. Explain more about the FTP destination. Is the file 

being sent to Enclarity? 


For the test PD data file, how many records are deemed appropriate for each provider 

type? 

13255 

13256 

13258 

13260 

#30 for the independent network are we providing the word “Independent” or are 

we adding the clinic name if the provider belongs to a clinic? 

Will we be able to correct file errors and have them updated, or will updates have to 

wait until the next quarterly submission? 

I understood you to say that specialties would drive the value of Provider Type. Please 

provide a list of what specialties indicate a provider type of 'V' and what specialties 

indicate a provider type of 'D', so we know what value to use for this column for our 

providers. 

Our Pharmacy group has heard conflicting information on when the formulary is due to 

the Exchange. I have heard that the Exchange is not reviewing the formulary, so does 

that mean the formulary is not due until after QHP certification? 




closed 


We have poured over the instructions for technical testing but cannot find answers to 

the following questions. I cannot tell from the Q&A on the phone whether we need to 

adhere to the April 1 deadline or if or if we have until April 15 to provide plan, benefit 

and rate data for testing? Also, under these tight timeframes, could you please provide 

information on the following: 

1. We need to sign a Trading Partner Agreement with CalHEERS to be allowed 

to test and be certified. Please send us the agreement and instructions. 

2. Complete communication connectivity testing. Please send details about the 

Enclarity FTP site, provide access and instructions. 

3. Provider Network Input file layout specific questions: 

a. Field 1 - Provider ID - Can this field have any length? Do you have any other 

specific requirements for this field? 

b. Field 52 - PCP ID - This field is noted as Situational and comments indicate 

Required for Medi-Cal Plans only. Do you want the health plan internal PCP ID (field 1) 

or some other PCP ID. If other, please specify what ID number is required and how 

this will be used to ensure contractor provides the appropriate PCP ID in field 52. 

c. Field 54 - Accessibility Codes - Field is defined as varchar(1). How are six 

different codes to be identified in the space of one? 

d. Field 55 - Location ID, contractor's Service Location ID will exceed 10 

characters. Can this field be lengthened? 

e. Field 56 - Issuer Name - Has a 30 character limit and contractor's issuer 

name is 31 characters. Can the field be extended or can contractor abbreviate? Will 

this field be displayed to beneficiaries? 

13275 test strategy Enrollment Q: When will the testing schedule for CA HIX be published? 

13276 

Contractor Q: Are details related to file transfer (file names, servers and protocols) 

available for all file transfers? Where are these details available? 

13280 

Will Covered California post notes/minutes on this call because the speaker is going 

through the material so fast that it is impossible to get everything down. 

13284 

Is the only agent/broker information captured on the enrollment application and 834 the 

broker name and broker ID? 

13285 834 

834 Q: In the last section of the guide, it states the a reconciliation report must be 

returned to Covered CA. In what form must that report be in? 

1. What format should the carriers use for the monthly discrepancy report? 

2. When can the carriers expect to receive the monthly reconciliation file? 

3. What will be the format of the reconciliation file from CC? Will it be a full file of 

active members? 

13286 834 834 How are we reporting back the monthly discrepancies to you? 

13288 834 

Address Changes: Does this mean you will send two iterations of the same member 

within one ST to SE? Or does this mean you will send two ST to SE‟s? 

13289 834 

IND Market Re-enrollment: What to do with coverage in case of subscriber death – 

term effective on date of death, but all effective is 1st of month? 

13290 834 

Shop: If a group cancels for nonpayment would there be no reinstatement? The topic 

of this webinar was the Plan guide. Will you go over this information again at the 834 

meeting next week? 

13291 834 

In the last section of the 834 guide, it states the a reconciliation report must be returned 

to Covered CA. In what form must that report be in? 

13292 

Is the only agent/broker information captured on the enrollment application and 834 the 

broker name and broker ID? 


Provider directory Q: How is the exchange defining Network and how will it be used? 




closed 




Provider directory Q: Tier ID : Is it always concatenated to the Network ID with an 

underscore? 

Provider directory Q: Tier ID; Are the values always 1 and 2. How will Tier be defined 

by the exchange and how will it be used? 

Provider directory Q: While the NPI is a required element, we do not have it for all 

providers: providers who do not bill Medicare are not motivated to provide it. Therefore 

it will be blank for some providers. How do we handle this currently required field given 

this reality? 


Provider directory Q: When will taxonomy codes and specialty codes be available? Can 

you confirm they will be standard CMS codes. 


Provider directory Q: Specialty Name - Will we receive the name along with the CMS 

Specialty Code Standard? 


Provider directory Q: Confirm that only active providers should be sent to the 

exchange. 

13300 

1. Will an SLA be given for all interfaces to and from the Exchanges, 

including acknowledgements? 

13302 834 

3. How will a member's premium amount be sent in the 834? Will you send the actual 

amount the member is responsible for. So, will subtracting the APTC from the 

premium amount equal the exact amount a member owes? Will the carriers be 

required to make any additional calculations? 

13303 834 

4. Please confirm that groups will be directed to a carrier's portal to make a payment. 

Once you're received a confirmation that the carrier has loaded an employer group you 

will send the 834 to enroll members. Also, confirm that you will not send enrollment 

until groups have been effectuated. 

13306 834 

2. Regarding the answer to the subscriber and the oldest person, does this apply to 

individual and SHOP or SHOP only? 

13307 834 3. What is the process for CC to receive and send APTC to members in the 834? 

13308 834 4. Will the carriers be required to reconcile APTC and CSR with CC. 

13310 FFE 

Are there any areas where Covered CA is going beyond the delta/baseline set by FFE 

guidelines? 

13315 SERFF When can we expect the Rate template business rules? 

13316 SERFF 

Has CA addressed the issue of validation of serff submissions with the feds? Since we 

are using „dummy‟ data, it may not meet criteria for validation. 


Should we send Pharmacy network data (e.g. Pharmacies) to the Exchange in our 

Provider Directory in order to allow potential customers to check if a Pharmacy is in our 

Network? 

13319

130405 0242 Open Issue Tracker - California Health Benefit Exchange

Create successful ePaper yourself

Delete template?

Save as template?