Washington Health Benefit Exchange
CARRIER TESTING OVERVIEW &
834 DRAFT COMPANION GUIDE REVIEW
February 27, 2013
1:00-3:00 PM
Agenda
Topic
Welcome
• Introductions
• Purpose of the Meeting
Facilitator
Duration
Lauren Schaub
10 Min
Testing Onboarding Overview
Paul Price
45 Min
Review of DRAFT 834 Companion Guide
Jacques Michel
60 Min
Questions, Wrap up, and Next Steps
Lauren
5 Min
Carrier Testing Overview
▪ Interface Testing Coordinator
▪ Technical Contact
▪ Interface Testing Process Guide
▪ Connectivity Testing
▪ Transaction Testing – 834, 820, 999
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Coordinator and Technical Contact
▪ Interface Testing Coordinator
▪ Paul Price 360-407-4117
▪ paul.price@wahbexchange.org
▪ Technical Contact
▪ Don Cotey 360-407-4112
▪ don.cotey@wahbexchange.org
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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
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Connectivity Testing
▪ Begin March 15, 2013
▪ Site – ftp.wahbexchange.org
▪ Folder structure: Outbound, Inbound, Ack,
Errors
▪ Accounts: 1 per carrier per test type,
permitted through firewall by IP address
and SSL certificates.
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Connectivity Testing
▪ Test
▪ Telnet/ftp
▪ Drop and read files
▪ Testers and support on conference
call during testing activities
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Transaction Testing
▪ Technical Review
▪ Integration – Hybrid of Carrier and
Generic Data
▪ UAT – Carrier Specific Data
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Transactions – Technical Review
▪ Design Specification
▪ HIPAA Compliance
▪ EDI Compliance – Level 2
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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
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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 carrierspecific transaction files
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834 Companion Guide
Individual Market
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834 Transaction Flow
Primary Applicant
Exchange Call Center /
Enrolment Account
Worker / Broker
Washington Healthplanfinder
Initial Enrollment
Update Member Information
Compare Plans
Select Plan
Initiate Payment
Add Member
Remove Member
Eligibility Change
Demographic Info Change
Health Benefit
Exchange System
HBE puts 834 files
in Outbound Folder
Folder Structure
Outbound Folder
Carrier
Ack Folder
Carrier Acknowledges
with 999 for HBE
Issuer Processing
System
Inbound Folder
• 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.
Error Folder
• The Trading Partner will
return a 999
Acknowledgement file to
confirm the transaction.
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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.
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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 copayments 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.
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Enrollment Transactions Business Rules
▪ The Exchange will send Enrollments, Changes and Terminations transactions. Reenrollments 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.
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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.
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WA HBE Technical Meeting Schedule
Date
Agenda
Notes
February 27th
834 DRAFT Companion Guide
Comments due by 3/14
March 6th
Customer Service Overview
March 13th
Retro Enrollment and Disenrollment
March 20th
TBD
March 26th
Reconciliation Overview
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