KY MMIS 834 Companion Guide - Kymmis.com

KY MedicaidKY MMIS 834 Companion Guide Benefit Enrollmentand Maintenance (ASC X12N 834)Companion GuideVersion 3.0_FINALVersion 005010 X220A1Cabinet for Health and Family ServicesDepartment for Medicaid ServicesDecember 9, 2011

Document Change LogVersion Changed Date Changed By Reason1.0 10/20/2011 HPES DMS approved version.

Commonwealth of Kentucky – MMISKY MMIS 834 Companion GuideTable of ContentsKY MMIS 834 Companion Guide Benefit Enrollment and Maintenance (ASC X12N 834) ................................ 1Companion Guide ........................................................................................................................................................ 11 Introduction ......................................................................................................................................................... 11.1 Purpose ....................................................................................................................................................... 11.2 Special Considerations for 834 Transaction ............................................................................................ 21.2.1 Subscriber, Insured = Member in the Kentucky Medicaid Eligibility Verification System . 21.2.2 The following changes to a member will result in an 834 record being generated to thereceiver on a Daily or Recon 834 file: ...................................................................................................... 21.2.3 File Naming Standards ................................................................................................................ 22 Control Segment Definitions For Kentucky Medicaid .................................................................................... 42.1 ISA - Interchange Control Header Segment ........................................................................................... 42.2 IEA - Interchange Control Trailer ........................................................................................................... 52.3 GS – Functional Group Header ................................................................................................................ 52.4 GE – Functional Group Trailer ................................................................................................................ 62.5 ST – Transaction Set Header .................................................................................................................... 72.6 SE – Transaction Set Trailer .................................................................................................................... 82.7 Valid Delimiter s for Kentucky Medicaid EDI ......................................................................................... 83 Companion Guide For The 834 Transaction .................................................................................................... 94 HD04 Data Element Layout ............................................................................................................................. 22DMS Approved 12/02/2011Page i

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide1 IntroductionThe Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all otherhealth insurance payers in the United States comply with the EDI standards for health care as establishedby the Secretary of Health Services. The ANSI X12N implementation guides have been established asthe standards of compliance for claim transactions.The following information is intended to serve only as a companion guide to the HIPAA ANSI X12Nimplementation guides. The use of this guide is solely for the purpose of clarifying the Cabinet for Healthand Family Services Department for Medicaid Services use of the Health Care Benefit Enrollmenttransaction. The information describes specific requirements to be used for processing data. Thiscompanion guide supplements, but does not contradict any requirements in the X12N implementationguide. Additional companion guides/trading partner agreements will be developed for use with otherHIPAA standards, as they become available.Additional information on the Final Rule for Standards for Electronic Transactions can be found athttp://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed athttp://www.wpc-edi.com/hipaa/HIPAA_40.asp.1.1 PurposeThe 834 Transaction is used to transfer enrollment information from the sponsor of the insurancecoverage, benefits, or policy to a payer. The intent is the initial enrollment and subsequent maintenanceof individuals who are enrolled in healthcare. This transaction specifically addresses the enrollment andmaintenance of healthcare only.Providers of healthcare or services may include entities such as physicians, hospitals, other medicalfacilities or suppliers, dentists, pharmacies and entities providing medical information to meet regulatoryrequirements.The payer refers to a third party entity that pays claims or administers the insurance benefit.A sponsor is the party that ultimately pays for the coverage or benefit.A member is an individual eligible for coverage because of his or her association with a sponsor. Aninsured individual is a member who has been enrolled for coverage under Kentucky Medicaid.DMS Approved 12/02/2011 Page 1

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide1.2 Special Considerations for 834 Transaction1.2.1 Subscriber, Insured = Member in the Kentucky Medicaid Eligibility Verification SystemThe Commonwealth of Kentucky Medicaid Eligibility Verification System does not allow for dependentsto be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers withineach program or MCO (Managed Care Organization).1.2.2 The following changes to a member will result in an 834 record being generated to thereceiver on a Daily or Recon 834 file:• SSN – Member SSN Change;• Gender – Member Gender Change;• Rate Cell – New Rate Cell Added or Changed that is different than the last KAMES filereceived;• Eligibility Effective Date – This is the Eligibility Start Date (Benefit Assignment);• Eligibility End Date – This is the Eligibility End Date (Benefit Assignment);• Member Name – Member Name Change that is different than the last KAMES file received;• Region – Member Changed Region that is different than the last KAMES file received;• TPL Resource Information -o TPL suspect code not = 2, 3, or 5;• Managed Care Assignment Add or Change date – Member joins MCO or New MCO or MCOdate changes;• Medicaid Number – Member Medicaid Number Change ;• Non-Institutional Hospice Institutional Status Code Change into or out of Non-InstitutionalHospice Care;• Institutional Status Code P1, P2, P4, P6, P7, R1 or M2 Change into or out of Institution;• Patient Liability Amount – Members non-Institutional Hospice Patient Liability Amount ;• Medicare Part A or Part B – Member effective or end date in Medicare Change ;• Foster Care – Member is placed into or out of Foster Care ;• Pregnancy – Member notifies Caseworker of Pregnancy and Expected Delivery Date ;o Future Dates will Apply and will be sent on Daily File as soon as Information isreceived by MMIS;o Only one PRG segment will be sent on an 834; and,o PRG segment will no longer be sent after the end of the month of the ExpectedDelivery Date.• Linked Member – Member ID is linked to Another Member IDo History of linked Members will be Sent unless a Member ID is unlinked• An unlinked Member will result in an Add on the subsequent Daily File andno LKD segment will be sent for that ID1.2.3 File Naming Standards• KYDELIG_MCO MMIS ID_DATE_TIMESTAMP;o Where D = Daily;o Where MCO MMIS ID = 10 digit Trading Partner ID;o Where DATE = File creation date;o Where TIMESTAMP = Time file created;• KYRELIG_MCO MMIS ID_DATE_TIMESTAMP;o Where R = Recon;DMS Approved 12/02/2011 Page 2

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guideo Where MCO MMIS ID = 10 digit Trading Partner ID;o Where DATE = File creation date;o Where TIMESTAMP = Time file created ;• KYMELIG_MCO MMIS ID_DATE_TIMESTAMP;o Where M = Monthly;o Where MCO MMIS ID = 10 digit Trading Partner ID;o Where DATE = File creation date; and,o Where TIMESTAMP = Time file created.DMS Approved 12/02/2011 Page 3

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide2 Control Segment Definitions For Kentucky Medicaid‣ ISA – Interchange Control Header Segment‣ IEA – Interchange Control Trailer Segment‣ GS – Functional Group Header Segment‣ GE – Functional Group Trailer Segment‣ ST – Transaction Set Header‣ SE – Transaction Set TrailerX12N EDI Control Segments2.1 ISA - Interchange Control Header SegmentCommunications transport protocol interchange control header segment. This segment within the X12Nimplementation guide identifies the start of an interchange of zero or more functional groups andinterchange-related control segments. This segment may be thought of traditionally as the file headerrecord.834 Benefit Enrollment and MaintenancePage Loop Segment Data Element CommentsC.4 N/A ISA ISA01 - Authorization InformationQualifierC.4 N/A ISA ISA02 - Authorization Information [space fill]'00' – No AuthorizationInformation PresentC.4 N/A ISA ISA03 - Security InformationQualifier'00' – No SecurityInformation PresentC.4 N/A ISA ISA04 - Security Information [space fill]C.4 N/A ISA ISA05 - Interchange ID Qualifier 'ZZ' – Mutually DefinedC.4 N/A ISA ISA06 - Interchange Sender ID ‘KY Medicaid' – Sender IDC.5 N/A ISA ISA07 - Interchange ID Qualifier 'ZZ' – Mutually DefinedC.5 N/A ISA ISA08 - Interchange Receiver ID ‘ID Supplied by KYMedicaid' – Receiver IDC.5 N/A ISA ISA09 - Interchange Date The date format isYYMMDDDMS Approved 12/02/2011 Page 4

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and MaintenancePage Loop Segment Data Element CommentsC.5 N/A ISA ISA10 - Interchange Time The time format is HHMMC.5 N/A ISA ISA11 – Repetition Separator ‘^’ – Repetition SeparatorC.5 N/A ISA ISA12 - Interchange Control Version ‘00501’ – Control VersionNumberNumberC.5 N/A ISA ISA13 – Interchange ControlNumberInterchange Unique ControlNumberC.6 N/A ISA ISA14 - Acknowledgment Requested ‘0’ – No AcknowledgementRequested‘1’ – AcknowledgementRequestedC.6 N/A ISA ISA15 – Interchange Usage Indicator ‘T’ - Test Data‘P’ - Production DataC.6 N/A ISA ISA16 - Component ElementSeparator‘:’ – Component ElementSeparator2.2 IEA - Interchange Control TrailerCommunications transport protocol interchange control trailer segment. This segment within the X12Nimplementation guide defines the end of an interchange of zero or more functional groups andinterchange-related control segments. This segment may be thought of traditionally as the file trailerrecord.834 Benefit Enrollment and MaintenancePage Loop Segment Data Element CommentsC.10 N/A IEA IEA01 - Number of includedFunctional GroupsNumber of includedFunctional GroupsC.10 N/A IEA IEA02 - Interchange Control Number Must be identical to thevalue in ISA132.3 GS – Functional Group HeaderCommunications transport protocol functional group header segment. This segment within the X12Nimplementation guide indicates the beginning of a functional group and provides control informationDMS Approved 12/02/2011 Page 5

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guideconcerning the batch of transactions. This segment may be thought of traditionally as the batch headerrecord.834 Benefit Enrollment and MaintenancePage Loop Segment Data Element CommentsC.7 N/A GS GS01 - Functional IdentifierCodeC.7 N/A GS GS02 - Application Sender’sCodeC.7 N/A GS GS03 - Application Receiver’sCode'BE' – Benefit Enrollment andMaintenance (834)This will be equal to the valuein ISA06.This will be equal to the valuein ISA08.C.7 N/A GS GS04 - Date The date format isCCYYMMDDC.8 N/A GS GS05 – Time The time format is HHMMC.8 N/A GS GS06 - Group Control Number Group Control NumberC.8 N/A GS GS07 - Responsible AgencyCodeC.8 N/A GS GS08 -Version/Release/ Industry IDCode‘X’ – Responsible Agency Code'005010X220A1' – Version /Release / Industry IdentifierCode2.4 GE – Functional Group TrailerCommunications transport protocol functional group trailer segment. This segment within the X12Nimplementation guide indicates the end of a functional group and provides control information concerningthe batch of transactions. This segment may be thought of traditionally as the batch trailer record.DMS Approved 12/02/2011 Page 6

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and MaintenancePage Loop Segment Data Element CommentsC.9 N/A GE GE01 – Number of TransactionSets IncludedNumber of included TransactionSetsC.9 N/A GE GE02 – Group Control Number Must be identical to the value inGS062.5 ST – Transaction Set HeaderCommunications transport protocol transaction set header segment. This segment within the X12Nimplementation guide indicates the start of the transaction set and assigns a control number to thetransaction. This segment may be thought of traditionally as the claim header record.834 Benefit Enrollment and MaintenancePage Loop Segment Data Element Comments31 N/A ST ST01 – Transaction Set Identifier '834' – Benefit Enrollment andCodeMaintenance31 N/A ST ST02 – Transaction Set ControlNumber31 N/A ST ST03 – ImplementationConvention ReferenceTransaction Control Number'005010X220A1' – Version /Release / Industry IdentifierCodeDMS Approved 12/02/2011 Page 7

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide2.6 SE – Transaction Set TrailerCommunications transport protocol transaction set trailer. This segment within the X12N implementationguide indicates the end of the transaction set and provides the count of transmitted segments (includingthe beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the claimtrailer record.834 Benefit Enrollment and MaintenancePage Loop Segment Data Element Comments184 N/A SE SE01 – Number of IncludedSegments184 N/A SE SE02 – Transaction Set ControlNumberTotal Number of Segmentsincluded in Transaction SetIncluding ST and SE.Must be identical to the value inST022.7 Valid Delimiters for Kentucky Medicaid EDIDefinition ASCII Decimal HexadecimalSegment Separator ~ 126 7EElement Separator * 42 2ACompound Element Separator : 58 3ARepetition Separator ^ 94 5EDMS Approved 12/02/2011 Page 8

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide3 Companion Guide For The 834 Transaction834 Benefit Enrollment and MaintenancePage Loop Segment Data Element Comments32 N/A BGN BGN01 - Transaction Set PurposeCode‘00’ – Original33 N/A BGN BGN02 – Transaction SetReference Number33 N/A BGN BGN03 – Transaction Set CreationDate33 N/A BGN BGN04 – Transaction Set CreationTime‘1’ – value 1 will be sentFormat: CCYYMMDDFormat: HHMMSS33 N/A BGN BGN05 - Time Zone Code ‘ES’ – Eastern Standard Time35 N/A BGN BGN08 – Action Code ‘2’ – Daily‘4’ - Monthly37 N/A DTP DTP01 – Date/Time Qualifier ‘007’ – Effective37 N/A DTP DTP02 – Date/Time Period FormatQualifier‘D8’ Date Expressed inFormat CCYYMMDD37 N/A DTP DTP03 – Date/Time Period File Effective Date38 N/A QTY QTY01 – Quantity Qualifier ‘TO' - Total38 N/A QTY QTY02 – Record Totals Total Number of MembersIncluded in File39 1000A N1 N101 – Entity Identifier Code ‘P5’ – Plan Sponsor Name39 1000A N1 N102 - Plan Sponsor Name ‘COMMONWEALTH OFKENTUCKY’DMS Approved 12/02/2011 Page 9

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance40 1000A N1 N103 - Identification CodeQualifier‘FI’ – Federal TaxpayerIdentification Number40 1000A1 N1 N104 – Sponsor Identifier ‘610600439’41 1000B N1 N101 – Entity Identifier Code ‘IN’ - Insurer41 1000B N1 N102 - Insurer NameThis is the 10 digit TradingPartner ID of the MCO42 1000B N1 N103 - Identification CodeQualifier‘FI’ – Federal TaxpayerIdentification Number42 1000B N1 N104 – Insurer Identification Code This is the 9 digit FederalTaxpayer IdentificationNumber of the MCO48 2000 INS INS01 - Member Indicator ‘Y’ - Yes48 2000 INS INS02 - Individual RelationshipCode‘18’ – Self49 2000 INS INS03 – Maintenance Type Code ‘001’ – Change‘021’ – Addition‘024’ – Cancellation orTerminationOne of these codes will besent per Loop 2000 on thedaily transaction‘030’ – Audit or CompareThis code is always sent onthe monthly transactionDMS Approved 12/02/2011 Page 10

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance49 2000 INS INS04 - Maintenance ReasonCode‘07’ Termination of Benefits’25’ – Change in IdentifyingData Elements‘28’ – Initial Enrollment‘33’ – Personnel Data‘AI’ – No Reason Given‘XN’ Notification Only51 2000 INS INS05 – Benefit Status Code ‘A’ - Active51 2000 INS INS06-1 - Medicare Plan Code ‘A’ – Medicare Part A‘B’ – Medicare Part B‘C’ – Medicare Part A andMedicare Part B‘ E‘ – No Medicare52 2000 INS INS08 - Employment Status Code 'FT' - Fulltime‘TE’ - Temporary53 2000 INS INS10 - Handicap Indicator ‘N’ – No53 2000 INS INS11 – Date/Time Period FormatQualifier‘D8’ - Date Expressed inFormat CCYYMMDD54 2000 INS INS12 - Member Individual Death Member date of deathDate55 2000 REF REF01 – Reference IdentificationQualifier‘0F’ – Member Number55 2000 REF REF02 - Member Identifier Members current Medicaid IDDMS Approved 12/02/2011 Page 11

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance56 2000 REF REF01 – Reference IdentificationQualifier‘1L’ – Member PolicyNumber56 2000 REF REF02 - Member Group or PolicyNumberMember SSN57 2000 REF REF01 – Reference IdentificationQualifierThis occurrence of the REFsegment can repeat up to 5times. One for each of thefollowing:‘‘F6’ – HIC Number‘3H’ – Case Number‘Q4’ – Prior ID Number‘23’ – Client Number’17‘ – Client ReportingCategory58 2000 REF REF02 - Member SupplementalIdentifierF6 = Member HIC Number3H = Member Case NumberQ4 = Member PreviousMedicaid ID23 = Member Original ID17 = MCO Selection TypeA = Auto-assignedM = Member Selected59 2000 DTP DTP01 – Date Time Qualifier ‘356’ – Eligibility Begin Date60 2000 DTP DTP02 – Date Time Period FormatQualifier‘D8’ – indicates formatCCYYMMDD61 2000 DTP DTP03 – Eligibility Begin Date Date Medicaid EligibilityBegins59 2000 DTP DTP01 – Date Time Qualifier ‘357’ – Eligibility End Date60 2000 DTP DTP02 – Date Time Period FormatQualifier‘D8’ – indicates formatCCYYMMDDDMS Approved 12/02/2011 Page 12

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance61 2000 DTP DTP03 – Eligibility End Date Date Medicaid EligibilityEnds59 2000 DTP DTP01 – Date Time Qualifier ‘473’ – Medicaid Begin Date60 2000 DTP DTP02 – Date Time Period FormatQualifier‘D8’ – indicates formatCCYYMMDD61 2000 DTP DTP03 – Medicaid ApplicationStart DateDate Medicaid Applicationwas entered into CountyOffice System59 2000 DTP DTP01 – Date Time Qualifier ‘474’ – Medicaid End Date60 2000 DTP DTP02 – Date Time Period FormatQualifier'D8’ – indicates formatCCYYMMDD61 2000 DTP DTP03 – Medicaid Re-Determination DateDate County Office redeterminesMember Medicaideligibility qualifications62 2100A NM1 NM101 –Entity Identifier Code ‘74’ – Corrected Insured63 2100A NM1 NM102 – Entity Type Qualifier 1' - Person‘IL’ – Insured or Subscriber63 2100A NM1 NM103 – Member Last Name Member Last Name63 2100A NM1 NM104 – Member First Name Member First Name63 2100A NM1 NM105 – Member Middle Initial Member Middle Initial64 2100A NM1 NM108 - Identification CodeQualifier‘34’ – Member SSN64 2100A NM1 NM109 – Member Identifier 9 digit SSNDMS Approved 12/02/2011 Page 13

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance66 2100A PER PER01 – Contact Function Code ‘IP’ – Insured Party66 2100A PER PER03 - Communication NumberQualifier‘TE’ – Telephone66 2100A PER PER04 - Communication Number Member Telephone Number ifon file68 2100A N3 N301 - Member Address Line When applicable MemberAddress68 2100A N3 N302 – Member Address Line When applicable MemberAddress69 2100A N4 N401 – Member City Name When applicable MemberCity, State, Zip Code69 2100A N4 N402 – Member State Code When applicable MemberCity, State, Zip Code70 2100A N4 N403 – Member Zip Code When applicable MemberCity, State, Zip Code70 2100A N4 N405 - Location Qualifier ‘CY’ – County70 2100A N4 N406 - Location Identifier Three digit Kentucky assignedcounty code71 2100A DMG DMG01-Date Time Period FormatQualifier‘D8’ – Date Expressed inFormat CCYYMMDD71 2100A DMG DMG02 – Member Birth Date Member Date of Birth72 2100A DMG DMG03 – Gender Code Member GenderF= FemaleM = MaleU = Unknown (This code is tobe used only when the genderis unknown or when it cannotbe sent due to reportingrestrictions.)DMS Approved 12/02/2011 Page 14

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance73 2100A DMG DMG05-1 – Race or EthnicityCode73 2100A DMG DMG05-2 – Code List QualifierCode74 2100A DMG DMG05-3 – Race or EthnicityCodeThis is the Member’s racecode‘7’ - Not Provided‘8’ – Not Applicable‘A’ - Asian or Pacific Islander‘B’ - Black‘C’ - Caucasian‘D’ – Subcontinent AsianAmerican‘E’ – Other Race or Ethnicity‘F’ – Asian Pacific American‘G’ – Native American‘H’ - Hispanic‘I’ - American Indian orAlaskan Native‘J’ – Native Hawaiian‘N’ - Black (Non-Hispanic)‘O’ - White (Non-Hispanic)‘P’ – Pacific Islander‘Z’ – Mutually Defined‘RET’ – Classification ofRace or EthnicityMember Ethnicity Code79 2100A ICM ICM01 – Frequency Code ‘4’ – Monthly80 2100A ICM ICM02 – Wage Amount Monthly Income84 2100A LUI LUI01 - Identification CodeQualifier‘LE’ – Language CodeDMS Approved 12/02/2011 Page 15

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance85 2100A LUI LUI02 – Language Code ISO 639 Language Codes whichinclude:‘SPA’ – Spanish‘ARM’ – Armenian‘KHM’ – Khmer‘TGL’ – Tagalog‘LAO’ – Laotian‘UNK’ – Unknown‘IRA’ – Iranian (Other)‘RUS’ – Russian‘ARA’ – Arabic‘JPN’ – Japanese‘ENG’ – English‘KOR’ – Korean‘POR’ – Portuguese‘UND’ – Undetermined‘VIE’ – Vietnamese‘FRE’ – French‘GER’ – German‘ITA’ – Italian86 2100B NM1 NM101- Entity Identifier Code ‘70’ – Prior Incorrect Insured87 2100B NM1 NM102 – Entity Type Qualifier ‘1’ – Person87 2100B NM1 NM103 – Prior Incorrect MemberLast NameMember Last NameIf the member last name haschanged since the last filesent, this field will bepopulatedDMS Approved 12/02/2011 Page 16

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance87 2100B NM1 NM104 – Prior Incorrect MemberFirst Name87 2100B NM1 NM105 – Prior Incorrect MemberMiddle Initial87 2100B NM1 NM108 - Identification CodeQualifierMember First NameIf the member first name haschanged since the last filesent, this field will bepopulatedMember Middle InitialIf the member middle initialhas changed since the last filesent, this field will bepopulated‘34’ - Corrected MemberSSNIf the member SSN haschanged since the last filesent, this field will bepopulated88 2100B NM1 NM109 – Identification Code If the member SSN haschanged since the last filesent, this field will bepopulated89 2100B DMG DMG01 – Date Time PeriodFormat Qualifier90 2100B DMG DMG02 – Prior Incorrect InsuredBirth Date90 2100B DMG DMG03 – Prior Incorrect InsuredGender Code‘D8’ - Date Expressed inFormat CCYYMMDDMember Birth DateIf the member date of birthhas changed since the last filesent, this field will bepopulatedMember Gender CodeIf the member gender haschanged since the last filesent, this field will bepopulated92 2100C NM1 NM101- Entity Identifier Code 31 – Postal Mailing Address92 2100C NM1 NM102 – Entity Type Qualifier ‘1’ – PersonDMS Approved 12/02/2011 Page 17

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance94 2100C N3 N301 – Member Address Line Mailing Address 194 2100C N3 N302 – Member Address Line Mailing Address 295 2100C N4 N401 – Member Mail City Name Mailing Address City95 2100C N4 N402 – Member Mail State Code Mailing Address State96 2100C N4 N403 – Member Zip Code Mailing Address Zip Code114 2100F NM1 NM101- Entity Identifier Code ‘S3’ - Custodial Parent115 2100F NM1 NM102 – Entity Type Qualifier ‘1’ – Person115 2100F NM1 NM103 - Custodial Parent LastName115 2100F NM1 NM104 - Custodial Parent FirstNameCase Last NameCase First Name123 2100G NM1 NM101 - Entity Identifier Code ‘QD’ – Responsible Party124 2100G NM1 NM102 – Entity Type Qualifier ‘1’ – Person124 2100G NM1 NM103 - Responsible Party LastName124 2100G NM1 NM104 - Responsible Party FirstName124 2100G NM1 NM105 – Responsible PartyMiddle nameLast Name of ResponsiblePartyFirst Name of ResponsiblePartyMiddle Name of ResponsiblePartyDMS Approved 12/02/2011 Page 18

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance140 2300 HD HD01 - Maintenance Type Code ‘001' - Change‘021’ - Addition‘024’ - Cancellation orTermination‘030’ – Audit or CompareThis code is always sent onthe monthly transaction141 2300 HD HD03 - Insurance Line Code ‘HLT’ – Health141 2300 HD HD04 – Plan Coverage Description Plan Coverage DescriptionNote – See Section 4 – For thelayout of the HD04 dataelement142 2300 HD HD05 - Coverage Level Code ‘IND’ – Individual143 2300 DTP DTP01 – Date/Time Qualifier ‘348’ – Benefit Begin144 2300 DTP DTP02 – Date Time Period FormatQualifier‘349’ – Benefit EndThere will be 2 repetitions ofthis segment for each Loop2300 repetition except thePRG Loop 2300 record andLKD Loop 2300 record.'D8' - Date Expressed inFormat CCYYMMDDDMS Approved 12/02/2011 Page 19

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance144 2300 DTP DTP03 – Coverage Period Use to denote the begin andend dates for the various typesof coverage sent in the HD04– For HD04 PRG Loop 2300Records, Qualifier 348:This is the expected deliverymonth with a defaulted day.Please note: Pregnant womenare exempted from co-pay forprenatal, delivery, andpostpartum services (postpartum is 60 days fromdelivery) The eligibilitysystem (KAMES) will flag amember exempt from co-payfor the month of delivery andthe two calendar monthsfollowing delivery. Example-If a baby is delivered in June,the mother continues to beexempted until the last day ofAugust. The co-pay indicatoris passed in the HD04 ELGsegment (HD04-10).There will not be a seconditeration of the DTP segmentfor this type of Loop 2300.145 2300 AMT AMT01 - Amount Qualifier Code ‘D2’ – Deductible Amount tobe used for Patient Liability.This data element will only besent for HSP records in HD04145 2300 AMT AMT02 – Contract Amount This data element will only besent for HSP records in HD04152 2310 LX LX01 – Assigned Number ‘1’ – One PreferredProvider will be sent153 2310 NM1 NM101 - Entity Identifier Code ‘Y2’ – Managed CareOrganizationDMS Approved 12/02/2011 Page 20

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide834 Benefit Enrollment and Maintenance154 2310 NM1 NM102 – Entity Type Qualifier ‘1’ - Person154 2310 NM1 NM108 – Identification CodeQualifierSV - Service Provider (foratypical providers only)XX - National ProviderIdentifier155 2310 NM1 NM109 – Provider Identifier For SV in NM108 - 8 or 10digit Kentucky Medicaid IDNumberFor XX in NM108 - 10 digitNational Provider Identifier155 2310 NM1 NM110 – Entity RelationshipCode'72' - UnknownDMS Approved 12/02/2011 Page 21

Commonwealth of Kentucky – MMISKY MMIS 834 Companion Guide14 HD04 Data Element Layout2345HD04 is 43 bytes in length and will be used to supply additional eligibility information. This data element has been formatted as follows:Medicare Part D - If a member has either Medicare Part A or Medicare Part B, then KY Medicaid auto-enrolls them into Medicare Part D. Theonly exception is if the member has opted out of Medicare Part D.***NOTE: The “when applicable” fields will be set to spaces when they do not apply.Data Element Description Position with HD04Data ElementValid Values/Format/CommentsHD04-01 The coverage types Position 1 - 3 The first three bytes will denote the coverage typesand the possible values:'ELG' for Member eligibility'MNC' for Managed Care'MCA' for Medicare A'MCB' for Medicare B'GUA' for Member Guardianship'DJJ' for Member Department of Juvenile Justiceeligibility'FST' for Member Foster Care Information'PRG' for Member Pregnancy Information'HSP' for Member non-Institutional HospiceInformation'IST' for Member Institutionalized InformationDMS Approved 12/02/2011 Page 22

Commonwealth of Kentucky – MMISKY MMIS 834 Companion GuideData Element Description Position with HD04Data ElementValid Values/Format/Comments‘LKD’ for Linked Members InformationHD04-02 (always present)The HD04-01 segment number. Ifthere are 3 occurrences of the anyHD04-1 values, first HD04-2occurrence will have the value of 01,2nd occurrence will have the value of02 and the 3rd occurrence will havethe value of 03.Position 4 - 5 01 to 99For each Loop 2300 HD segment a Loop 2300 DTPsegment will be sent for the begin date and anotherLoop 2300 DTP segment for the end date. Only 1DTP segment will be sent for the PRG Loop 2300HD.HD04-03 (when applicable)The program code assignmentmaintained by senderPosition 6 - 7Value may be present for all coverage types"ELG", "MNC", "MCA", "MCB", “DJJ”, “GUA”,“FST”, “PRG”, "HSP", “IST”HD04-04 (when applicable)The IM ID assigned to the member bysenderPosition 8 - 9Value may only be present for coverage type"ELG"HD04-05 (when applicable)The status associated with the membereligibilityPosition 10 - 11Value may only be present for coverage type"ELG"HD04-06 (when applicable)The liability indicator assigned whenmember has patient liabilityPosition 12Value of "space"DMS Approved 12/02/2011 Page 23

Commonwealth of Kentucky – MMISKY MMIS 834 Companion GuideData Element Description Position with HD04Data ElementValid Values/Format/CommentsHD04-07 (when applicable)The Long Term Care indicator Position 13assigned when the member is in a LTCfacilityValue of "space"HD04-08 (when applicable)The Institutional Status Code assignedwhen the member is in an InstitutionalsettingPosition 14 - 15Value may only be present for coverage type"HSP", “IST”HD04-09 (when applicable) The Long Term Care PA indicator Position 16 Value of "space"HD04-10 (when applicable) The co-pay indicator Position 17 Value may only be present for coverage type"ELG"HD04-11 (when applicable)The transaction date associated withthis eligibility informationPosition 18 - 25Value may be present for all coverage types"MNC", "MCA", "MCB", “DJJ”, “GUA”, “FST”,“PRG”, “HSP”, “IST” , “LKD”Format: CCYYMMDDDMS Approved 12/02/2011 Page 24

Commonwealth of Kentucky – MMISKY MMIS 834 Companion GuideData Element Description Position with HD04Data ElementValid Values/Format/CommentsHD04-12 (when applicable) The member county code Position 26 - 28 Value may only be present for coverage type"ELG"HD04-13 (when applicable) Medicare Part D Opt Out Code Position 29 Value may only be present for coverage types"MCB", "MCA"If HD04-13 = Y, this means the member haselected not to be auto-enrolled into Medicare Part Dby KY Medicaid. If HD4-13 = N, then the memberis being auto-enrolled into Part D by KY Medicaid.HD04-14 (when applicable) The Member Pregnancy Indicator Position 30 Value may only be present for coverage type"PRG"HD04-15 (when applicable) The Member DJJ Indicator Position 31 Value may only be present for coverage type "DJJ"HD04-16 (when applicable) The Member Guardianship Indicator Position 32 Value may only be present for coverage type"GUA"HD04-17 (when applicable) The Member Foster Care Indicator Position 33 Value may only be present for coverage type"FST"HD04-18 (when applicable)Linked Member will be sent when aMember ID is linked to anotherMember ID – This is the InactiveMember Number – Loop 2000Subscriber 0F REF01 designates theActive MemberPosition 34 – 43Value may only be present for coverage type“LKD”6DMS Approved 12/02/2011 Page 25