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Carrier Testing Overview & 834 DRAFT Companion Guide Review

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Carrier Testing Overview & 834 DRAFT Companion Guide Review. February 27, 2013 1:00-3:00 PM. Agenda. Carrier Testing Overview. Interface Testing Coordinator Technical Contact Interface Testing Process Guide Connectivity Testing Transaction Testing – 834, 820, 999.

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carrier testing overview
Carrier Testing Overview
  • Interface Testing Coordinator
  • Technical Contact
  • Interface Testing Process Guide
  • Connectivity Testing
  • Transaction Testing – 834, 820, 999
coordinator and technical contact
Coordinator and Technical Contact
interface testing process guide
Interface Testing Process Guide
  • Contact Information
  • Roles and Responsibilities
  • Scope, Method, Approach
  • Environments and Connectivity
  • Support Hours
  • Test Scripts
  • Test Data
  • Defect Corrections, Tracking, Reporting, Cycles
  • Entrance and Exit Criteria
  • Validation Methods in Partner System
connectivity testing
Connectivity Testing
  • Begin March 15, 2013
  • Site –
  • Folder structure: Outbound, Inbound, Ack, Errors
  • Accounts: 1 per carrier per test type, permitted through firewall by IP address and SSL certificates.
connectivity testing1
Connectivity Testing
  • Test
    • Telnet/ftp
    • Drop and read files
    • Testers and support on conference call during testing activities
transaction testing
Transaction Testing
  • Technical Review
  • Integration – Hybrid of Carrier and Generic Data
  • UAT – Carrier Specific Data
transactions technical review
Transactions – Technical Review
  • Design Specification
  • HIPAA Compliance
  • EDI Compliance – Level 2
transactions integration testing
Transactions – Integration Testing
  • Hybrid Data
  • Carrier specific if Carrier supplied test data
    • 1 so far
  • Generic data for all other carriers
    • Plans, employers, households all uniform
    • Carrier test systems must be prepared in advance to consume and process the generic data
transactions uat
Transactions - UAT
  • Dependent on Carriers supplying test data
  • Expected to be easier after May 1st
  • Use CMS templates
  • Supply to HBE first week of May for use in UAT starting June 1st.
  • Healthplanfinder will produce carrier-specific transaction files
834 companion guide
834 Companion Guide

Individual Market

834 transaction flow
834 Transaction Flow

The Washington Health Benefit Exchange will send the 834 transactions to a QHP Carrier with enrollment information.

This transaction is created after an application has been determined eligible, a QHP selected, and payment initiated through the Healthplanfinder.

The Trading Partner will return a 999 Acknowledgement file to confirm the transaction.

member identifiers
Member Identifiers
  • The Washington HBE will use a unique identifier, Person ID, to manage individuals within the Exchange.
  • Person ID is communicated to the Carrier in the 834 transactions within the 2000 Member Level Detail loop.
    • The subscriber will have their own Person ID while each additional member eligible for coverage will also have their own Person ID.
    • Once an individual is assigned a Person ID, they keep this identifier for as long as they conduct business with the Exchange.
  • Washington expects that each Carrier will ensure that the Person ID is stored within the Carrier’s system(s) and be used as the key reference for all enrollments, changes, terminations and payments transactions involving the individual.
  • In most cases, each individual will also have a Social Security Number (SSN) that can be used as a secondary identifier in the 834 transmission. The SSN will also be able to be used to reconcile payments from the federal government.
general business rules
General Business Rules
  • Payer/Insurer: The payer is the party that pays claims and/or administers the insurance coverage, benefit or product.
  • Sponsor: A sponsor is the party that ultimately pays for the coverage, benefit, or product. A sponsor can be an employer, union, government agency, association, or insurance agency. This definition is being expanded to include the individual applicant.
  • Subscriber : The Subscriber is the person who elects the benefits and is responsible for the individual responsibility on premiums and the co-payments on claims. The subscriber is the Primary Applicant as received through the Washington Healthplanfinder. The subscriber may or may not be insured under the plan.
    • Note: The 834 will always identify the Primary Applicant as a Subscriber. When the Subscriber is not enrolled the Exchange will use the HD05 Coverage Level Code (2300 – Health Coverage) of Dependents Only “DEP” to indicate this condition.
  • Insured or Member : An insured individual or member is a subscriber or dependent who has been enrolled for coverage under an insurance plan.
enrollment transactions business rules
Enrollment Transactions Business Rules
  • The Exchange will send Enrollments, Changes and Terminations transactions. Re-enrollments are managed as a Termination followed by an Enrollment with new eligibility dates for the same subscriber (Person ID).
  • Multiple events reported by customers on the same day, are processed in the Exchange in chronological order and by priority of the type of change.
  • Since the subscriber is defined as the person who elects the benefits, the applicant is the subscriber. When the subscriber is not enrolled (for example in Child Only plans) we will use the coverage level code of Dependents Only “DEP” to indicate this condition.
  • All information about the monies associated with the insurance premium will be reported under the 2700 Member Reporting Categories loop of the subscriber. Financial information reported in the 2750 Loops (within the 2700 loop) include the premium amount (PRE AMT TOTAL), the APTC amount (APTC) and the total individual responsibility amount (TOT IND RES AMT). The sum of the APTC and the TOT IND RES AMT is always equal to the PRE AMT TOTAL.
  • In the event multiple tax filers are eligible for advance payments of tax credits (APTCs) within the same policy, the APTCS for all tax filers will be aggregated as a single amount and reported as a single amount within the subscriber 2700-2750 Reporting Categories.
enrollment transactions business rules1
Enrollment Transactions Business Rules
  • The Exchange will not include individual rating information in the 2700 loop.
  • Termination at the Member Level for the Subscriber indicates that all coverage for that Subscriber and any other associated dependents are to be terminated. The Exchange will send explicit terminations in the INS segment for each member.
  • Termination sent at the Member Level for an individual who is not the Subscriber terminates coverage only for that individual
  • A cancellation of coverage is a termination of health coverage PRIOR to the effective date of the health coverage. The enrollee would request through the Healthplanfinder that the health coverage they previously selected is cancelled prior to the first possible effective date.
  • The Exchange will not use the Responsible Person or Custodial Parent loops. The approach for non-covered subscriber compensates for their use.
  • The Exchange use of coverage dates in the 2300 Health Coverage loop is inclusive. A Benefit Begin date of 2/1/2014 indicates coverage is effective on that date. A Benefit End date of 2/1/2014 indicates coverage is effective on 2/1/2014 and ends on 2/2/2014. An enrollment transaction followed by a termination transaction for the same day of coverage indicates that coverage is effective that day.