KY MMIS 834 Companion Guide - Kymmis.com

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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
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KY MMIS 834 Companion Guide - Kymmis.com

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