HIPAA TransactionStandard Companion GuideASC X12N Version 005010X220A1834 Benefit and Enrollment MaintenanceGuide Version 1.2September 2, 2018

PrefaceThis Companion Document to the ASC X12N Implementation Guides adopted under HIPAAclarifies and specifies the data content when exchanging electronically with MagnaCare.Transmissions based on this companion document, used in tandem with the X12NImplementation Guides, are intended to be compliant with both X12 syntax and those guides.This Companion Guide is intended to convey information that is within the framework of theASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is notintended to convey information that in any way exceeds the requirements or usages of dataexpressed in the Implementation Guides.Companion Guide for ANSI X12 834 – Version 005010X220A12 of 20

Table of Contents1234Introduction. 41.1Scope . 41.2Overview. 41.3References . 41.4Additional Information . 4Before you begin . 52.1Important information . 52.2Registration . 52.3Testing Overview . 5Testing Procedures . 63.1Phases of Testing. 63.2Testing Process. 6Transfer of Information. 74.1Data Transfer . 74.2Administrative Transmission Procedures . 84.3Specification of Communication Protocol . 84.4Passwords . 94.5Encryption . 94.6FTP Server . 95Business Rules and Specifications . 96Additional Requests. 97Transaction Specification . 107.1Control Segments. 107.2834 Eligibility File Layout . 128Appendix . 189Example . 19Companion Guide for ANSI X12 834 – Version 005010X220A13 of 20

1Introduction1.1 ScopeThis Companion Guide is intended to support the implementation of a batch processingapplication. MagnaCare will accept inbound submissions that are formatted correctly in X12terms. The files must comply with the specifications outlined in this companion document aswell as the corresponding HIPAA implementation guide. MagnaCare Electronic DataInterchange (EDI) applications will edit for these conditions and reject files that are out ofcompliance. This companion document will specify everything that is necessary to conductEDI for this standard transaction.This includes: Communications link specifications Submission methods specifications Transaction specifications1.2 OverviewThis document is intended to compliment the ASC X12N implementation guide currentlyadopted from HIPAA. It is compliant with the corresponding HIPAA implementation guidesin terms of data element and code standards and requirements. It will be the vehicle thatMagnaCare uses with its Clients to further qualify the HIPAA-adopted implementationguides.Data elements that require mutual agreement and understanding will be specified in thiscompanion guide. Types of information that will be clarified within this companion are; Qualifiers that will be used from the HIPAA implementation guides to describe certaindata elementsSituational segments and data elements that will be utilized to satisfy business conditionsClient profile information for purpose of establishing who we are trading with for thetransmissions exchanged1.3 ReferencesASC X12N Implementation Guides1. Benefit Enrollment and Maintenance 834 e-5010-consolidated-guides1.4 Additional InformationElectronic Data Interchange (EDI) is the computer-to-computer exchange of formattedbusiness data between Clients, without human intervention. MagnaCare maintains adedicated staff for the purpose of enabling and processing X12 EDI transmissions with itsClients. It is the goal of MagnaCare to establish Client relationships and to conduct EDI asopposed to paper information flows whenever and wherever possible.Companion Guide for ANSI X12 834 – Version 005010X220A14 of 20

2 Before you begin2.1 Important informationClients will be working with two units within MagnaCare to implement EDI transactions: MagnaCare EDI Business support unit will serve as the Client’s central point of contact.This group will also facilitate the implementation of Clients through all steps of externaltesting. This group will coordinate closely with MagnaCare EDI team who will beaccepting and translating data on behalf of MagnaCare. MagnaCare corporate EDI IT group is a centralized technical team that implements thecommunication link and facilitates the acceptance or rejection of a Client’s EDI. Thisgroup maintains the EDI translator maps. They will also handle all issues relating to filesthat were accepted from our translator and moved forward to MagnaCare for processing.2.2 RegistrationTo register as a Client with MagnaCare, you will need to do the following:1. Initial conversations are held between the Client and MagnaCare.2. Verbal agreements are reached as to the transactions that will be conducted.3. A companion guide is provided and reviewed.4. Submitter Id and Receiver Id is established for the purpose of identification.5. Required Client profiling is built into our EDI translator.6. X12 compliant test files are exchanged and test runs conducted.7. Once the testing phase is completed, the Client is registered.2.3 Testing OverviewMagnaCare requires their Clients to do validations and test at their end or using third partycertification such as Claredi so that the process to test and implement a Client for the purposeof conducting EDI with standard transactions is smooth and efficient.The complexity of X12 files when not tested and certified by a third party will cause delays inthe ability to enable the X12 submissions in a production environment.MagnaCare wants to spend the majority of the testing period time, working with prospectiveClients on the agreed components of this companion document rather than X12 or HIPAAimplementation guide syntax.Companion Guide for ANSI X12 834 – Version 005010X220A15 of 20

3 Testing ProceduresMagnaCare would like to establish a set of scenarios intended for testing with the Client. Itshould be a representation at a high level or cross section of the majority of conditions that will beencountered with production data from these transactions.3.1 Phases of TestingMagnaCare requires testing to be completed with all Clients. The testing phase will consist ofseveral smaller phases of testing, as appropriate.3.1.1 Syntactic TestingMagnaCare uses an industry standard data translator, REDIX to validate transactionsand to translate them into an acceptable format for internal processing. Clients arerequired to validate files prior to sending. Any issues identified during this phase oftesting will have to be addressed in order for subsequent phases to continue.3.1.2 Compliance TestingClient specific setup, as defined in the companion guide will be verified. Generally,this will be done in conjunction with Syntactic testing.3.1.3 Scenario TestingThis will normally involve all possible business scenarios to be tested.3.1.4 Volume TestingThis will involve testing large eligibility files. We would like to receive eligibilityfiles with 50 members each representative of the actual population which will be senton the production files.3.2 Testing ProcessThe following summarizes the testing process:1 After initial contacts and agreements are made, Client will provide MagnaCare withits EDI certification.2 Next, the Client will provide the MagnaCare HIPAA project manager with one ormore files of the X12N formatted sample data, and samples of all relevant businessscenarios.3 MagnaCare HIPAA project manager will translate the files and then upload to theMagnaCare core system. Error messages or diagnostics will be relayed to the Client.This process will proceed by iteration until all parties are satisfied.4 Once format issues are settled, the communication protocols are similarlyimplemented and tested.5 Once the technical requirements have been settled and documented in thecompanion guide and it’s Appendix, the Client and MagnaCare will sign off on thecompanion guide and move the transaction into production.Companion Guide for ANSI X12 834 – Version 005010X220A16 of 20

4 Transfer of Information4.1 Data TransferData can be exchanged with MagnaCare via FTP over the Internet where the file is encrypted,sent over the Internet and then decrypted. For data inbound to MagnaCare (see Figure 1A),the Client would encrypt the data on an internal server, transfer it using FTP Client toMagnaCare’s FTP server. MagnaCare will then move the encrypted file from MagnaCare’sFTP server to an internal server where the file is decrypted and forwarded for processing.Figure 1AEncrypted Data sent over the Internet from Client to MagnaCare FTP ServerClientInternalServerFTP ClientINTERNETMagnaCareFTP ServerMagnaCareInternalServerMagnaCare data sent to Client (see Figure 1B). MagnaCare will generate the X12 data fileand encrypt it. Once encrypted, the file will be sent to MagnaCare’s FTP server. At that time,the Client can retrieve the file, transfer it to their internal system using FTP client, decrypt itand process it.Figure 1BEncrypted Data sent over the Internet from MagnaCare FTP Server to ClientMagnaCareInternalServerMagnaCareFTP ServerCompanion Guide for ANSI X12 834 – Version 005010X220A1INTERNETFTPClientClientInternalServer7 of 20

4.2 Administrative Transmission ProceduresAs part of the process establishing the relationship, MagnaCare and the Client must exchangecertain technical information.The requested information will include:1. Contacts: business, data and communications2. Dates: testing, production3. File information; size, naming4. Transfer; schedule, protocol5. Server information; host name, user ID, password, file location, file name6. Notification; failure, success4.2.1Re-transmission proceduresWhen a file needs to be re-transmitted, the Client will contact their primaryAccount Management contact at MagnaCare.4.3 Specification of Communication ProtocolThe following items are required from the Client in order to exchange data with MagnaCareutilizing FTP server over the Internet.1. Internet Connectivity; Client should consider a broadband connection for large files.2. Computer with FTP client and connectivity to the Internet.3. PGP software for encryption/decryption. RSA (or Legacy) keys must be generatedand exchanged with MagnaCare via e-mail (public keys only).4. E-mail capability to exchange configuration and testing information.Initial setup will include confirming FTP connectivity, exchanging PGP public keys andperforming end-to-end communications testing. Before sending data to MagnaCare, the datamust be encrypted with PGP and then sent to the MagnaCare FTP using the FTP client overthe Internet connection. When receiving data from MagnaCare, the FTP client will be used toget the data from the MagnaCare FTP server after which PGP will be used to decrypt thedata.MagnaCare provides following three connectivity options to establish interface with itsservers.1. MagnaCare offers FTP over SSL with explicit encryption. SSL (Secure Socket Layer)FTP provides reliable encryption for both the user login, and transferred files.2. SFTP (Secure File Transfer Protocol) is based on SSH2 (Secure Shell 2). SFTP providescomprehensive protection for a user's data, ID, and password by establishing a securechannel for file transfers. MagnaCare recommends SFTP for small-to-medium size filetransfers whenever possible.3. VPN (Virtual Private Network) option is available to larger clients with extensive datainterchange needs. VPN allows a user to connect directly to MagnaCare's LAN via acontrolled access point. The VPN protocol is used to establish a secure data tunnelbetween MagnaCare and a client or vendor, where large numbers of files are to beCompanion Guide for ANSI X12 834 – Version 005010X220A18 of 20

transferred periodically. If appropriate, VPN access must be pre-arranged, and configuredwith MagnaCare's IT Dept.4.4 PasswordsMagnaCare requires the use of User IDs and Passwords to access its systems and servers andwill assign each Client a unique User ID and password when using MagnaCare server. In theevent a Client forgets their password, MagnaCare will change the password after verifyingthe authenticity of the request.4.5 EncryptionMagnaCare requires the encryption of data that is exchanged via the Internet or any otherpublic network. MagnaCare utilizes Gnu PGP encryption with 1024 or 2048 bit keys for fileencryption.4.6 FTP ServerMagnaCare FTP server can be reached using the DNS name .MagnaCare highly recommend using the DNS name rather than the IP address of the server,as we have more than one FTP server available to meet our Disaster Recovery needs.5 Business Rules and Specifications Numeric fields should not be zero padded.Fields should not be space padded except ISA segment.All monetary amounts are to include decimal points with two positions allowed to the right ofthe decimal point to represent cents.Specific field descriptions may be found in the detailed file layout section of this CompanionGuide. Although some elements are situational, MagnaCare may require them and may alsorequire a specific value.6 Additional RequestsIf requested, 997 Acknowledgement will be sent so the Client will get confirmation that wereceived their submission.Companion Guide for ANSI X12 834 – Version 005010X220A19 of 20

7 Transaction Specification7.1 Control Segments7.1.1 ISA - INTERCHANGE CONTROL HEADERElementELEMENT DEFINITIONValuesDescriptionISA01AUTHORIZATION INFORMATIONQUALIFIER00No Authorization Information PresentISA02AUTHORIZATION INFORMATIONISA03SECURITY INFORMATION QUALIFIERISA04SECURITY INFORMATIONISA05INTERCHANGE ID QUALIFIERZZ30ISA06INTERCHANGE SENDER IDInbound: Client TIN/MagnaCareassigned Client CodeOutbound: 11-3038233ISA07INTERCHANGE ID QUALIFIERZZ30Mutually DefinedU.S. Federal Tax Identification NumberISA08INTERCHANGE RECEIVER IDInbound: 11-3038233Outbound: ClientTIN/MagnaCare assigned ClientCodeInbound: “11-3038233”Outbound: Client TIN/ MagnaCareassigned client Code.ISA09INTERCHANGE DATEYYMMDDDate of interchangeISA10INTERCHANGE TIMEHHMMTime of interchangeISA11INTERCHANGE CONTROL STANDARDSIDENTIFIER Repetition separatorISA12INTERCHANGE CONTROL VERSIONNUMBER00501Draft Standards approved by ASCX12ISA13INTERCHANGE CONTROL NUMBERAssigned by senderMust be identical to the interchangetrailer IEA02ISA14ACKNOWLEDGMENT REQUEST0No Acknowledgment RequestedISA15USAGE INDICATORP or TP Production, T TestISA16COMPONENT ELEMENT SEPARATOR[space fill]00No Security Information Present[space fill]Mutually DefinedU.S. Federal Tax Identification Number“:”NOTE: MagnaCare will accept only One ISA-IEA per file.7.1.2 IEA – INTERCHANGEElementELEMENT DEFINITIONIEA01NUMBER OF INCLUDED FUNCTIONALGROUPSIEA02INTERCHANGE CONTROL NUMBERCompanion Guide for ANSI X12 834 – Version 005010X220A1ValuesDescriptionNumber of included Functional GroupsAssigned by SenderMust be identical to the value in ISA1310 of 20

7.1.3 GS – FUNCTIONAL GROUP HEADERElementELEMENT DEFINITIONValuesDescriptionGS01FUNCTIONAL IDENTIFIER CODEBEBenefit Enrollment and MaintenanceGS02APPLICATION SENDER’S CODEInbound: MagnaCare assignedclient codeOutbound: MagnaCare TINSender’s code / Tax Identification NumberGS03APPLICATION RECEIVER’S CODEInbound: MagnaCare TINOutbound: MagnaCareassigned client codeReceiver’s code / Tax IdentificationNumberGS04DATECCYYMMDDGroup creation dateGS05TIMEHHMMCreation timeGS06GROUP CONTROL NUMBERGS07RESPONSIBLE AGENCY CODEXAccredited Standards Committee X12GS08VERSION/RELEASE/INDUSTRY IDENTIFIERCODE005010X220A1Version/Release/Industry Identifier CodeAssigned and maintained by the senderNOTE: MagnaCare will accept only one GS-GE per file.7.1.4 GE – FUNCTIONAL GROUP TRAILERElementGE01GE02ELEMENT DEFINITIONNUMBER OF TRANSACTION SETS INCLUDEDGROUP CONTROL NUMBERValuesDescriptionNumber of Transaction Sets IncludedMust be identical to the value in GS06Assigned by Sender7.1.5 ST – TRANSACTION SET HEADERElementST01ST02ELEMENT DEFINITIONTRANSACTION SET IDENTIFIER CODETRANSACTION SET CONTROL NUMBERValues834ST03IMPLEMENTATION CONVENTION REFERENCE005010X220A1DescriptionBenefit Enrollment and MaintenanceThe transaction set control numbers in ST02 and SE02must be Identical. This number must be unique within aspecific group and interchangeImplementation Guide Version NameNOTE: Magnacare can accept multiple ST-SE segments.7.1.6 SE – TRANSACTION SET TRAILERElementSE01ELEMENT DEFINITIONTRANSACTION SET IDENTIFIER CODEValuesSE02TRANSACTION SET CONTROL NUMBERAssigned bySenderDescriptionTotal number of segments included in a transaction setincluding ST and SE segments.The transaction set control numbers in ST02 and SE02 mustbe Identical. This number must be unique within a specificgroup and interchange.7.1.7 VALID DELIMITERS FOR MAGNACARE EDIDefinitionSegment SeparatorElement SeparatorCompound element SeparatorCompanion Guide for ANSI X12 834 – Version 005010X220A1ASCII\n (New Line)*:Decimal134258Hexadecimal2A3A11 of 20

7.2 834 Eligibility File LayoutThis table specifies the columns and suggested use of the rows for the detailed description of thetransaction set companion guides.834 Loops/Segments that MagnaCare will 1HIPAA FieldPositionSegment IDCONTROLBGN020-BGN01020-BGN02Interchange Control HeaderGSFunctional Group HeaderSTTransaction Set HeaderBGNBeginning SegmentDTPFile Effective DateREFTransaction Set Policy NumberSponsor NamePayerMember Level DetailREFSubscriber NumberREFMember Policy NumberREFMember Identification NumberDTPMember Level DatesMember NamePERMember Communications NumberN3Member Residence Street AddressN4Member Residence City, State, ZipDMGDemographicsDisability InformationDTPDisability Eligibility DatesHealth CoverageDTPHealth Coverage DatesProvider NameCoordination of BenefitsCOB DatesCOB Related EntityTrailer AA Data Element Name and PageNumber from Implementation GuideAttributesValid Values and CommentsMM ID 2/2M AN 1/30“00” OriginalNot used by MagnaCareM DT 8/8CCYYMMDD – Date submitter created the file.M TM 4/8Time submitter created the file in HHMM format.O ID 2/2Not used by MagnaCareO AN 1/30Not used by MagnaCare020-BGN07020-BGN08Beginning SegmentTransaction Set Purpose Code Pg 28Reference IdentificationINDUSTRY: Transaction Set IdentifierCodeDateINDUSTRY: Transaction Set Creation DateTimeINDUSTRY: Transaction Set CreationTimeTime CodeINDUSTRY: Time Zone CodeReference IdentificationINDUSTRY: Transaction Set IdentifierCodeSender DFI IdentifierAction CodeN/U ID 2/2O ID 1/2020-BGN09Security Level CodeN/U ID 2/2Not used by MagnaCare“4” - Verify (recommended)Any X12 action code may be used, but MagnaCaredoes not determine action from this codeNot used by nion Guide for ANSI X12 834 – Version 005010X220A112 of 20

HIPAA FieldPositionSegment ID1000REF030-REF01030-REF02HIPAA Data Element Name and PageNumber from Implementation GuideAttributesValid Values and CommentsSubscriber NumberReference Identification Qualifier Pg 32Reference IdentificationMM ID 2/3X AN 1/30“38” Master Policy NumberMagnaCare assigned Client Code (PPO only)1000QTY030-QTY01Transaction Set Control TotalsReference Identification Qualifier Pg 32OM AN 2/2030-QTY02Reference IdentificationM R 1/15New in 5010DT – Dependent Total, ET – Employee Total, TO TotalRecord TotalsSponsor NameEntity Identifier Code Pg35Plan Sponsor NameIdentification Code QualifierIdentification CodeINDUSTRY: Sponsor IdentifierMM ID 2/3M AN 1/60M ID 1/2M AN 2/80“P5” – Plan SponsorMagnaCare assigned Client Code (ASC only)“FI” - Federal Taxpayer’s Identification NumberSponsor Tax IDPayer NameEntity Identifier Code Pg37Insurer NameIdentification Code QualifierIdentification CodeINDUSTRY: Insurer Identification CodeMM ID 2/3M AN 1/60M ID 1/2M AN 2/80MM ID 1/1010-INS02Member Level DetailYes/No Condition or Response CodeINDUSTRY: Insured Indicator Pg 43Individual Relationship Code010-INS03010-INS04Maintenance Type CodeMaintenance Reason CodeO ID 3/3O ID 2/3010-INS05Benefit Status CodeM ID 1/1010-INS06010-INS07O ID 1/1O ID 1/2010-INS08Medicare Status CodeConsolidated Omnibus BudgetReconciliationAct (COBRA) QualifyingEmployment Status CodeREF020-REF01020-REF02Subscriber NumberReference Identification Qualifier Pg 51Reference IdentificationMM ID 2/3M AN 1/30REF020-REF01020-REF02Member Policy NumberReference Identification Qualifier Pg 53Reference IdentificationINDUSTRY: Insured Group or PolicyMM ID 2/3M AN mpanion Guide for ANSI X12 834 – Version 005010X220A1M ID 2/2O ID 2/2“IN” – Insurer“ZZ” – Mutually DefinedMagnaCare Assigned Client Code‘Y” – if Insured is a subscriber“N” – Insured is a dependent“18” – subscriber‘01” – Spouse“03” – Father or Mother“19” – ChildPlease refer to Guide for other Values“030” - Audit or Compare“XN” - Notification Only (This is used when INS03is equal to 030)“A” Active“C” Consolidated Omnibus Budget ReconciliationAct(COBRA)Changed to Composite element in 5010“FT” – Full time active employee“RT” – Retired“PT” – Part-time“0F” Subscriber NumberMember Social Security Number“1L” - Group or Policy NumberUp to 10 character Plan ID for PPOUp to 4 character MagnaCare Assigned Plan ID13 of 20

HIPAA FieldPositionSegment IDHIPAA Data Element Name and PageNumber from Implementation GuideAttributesNumberREF020-REF02Member Supplemental NumberReference Identification Qualifier Pg 55Valid Values and Commentsfor ASCMM ID 2/3Name change in 5010“ZZ”- Alternate ID“23” –Person Number. – Unique Person Identifiere.g. “01”, “02” This number must always be thesame in each update received and cannot containAlpha Char. The sequencing must start with “01”as member, “02” spouse, “03” first child, “04”next child . (ASC only)“DX” – Member Shop Number (ASC only)“F6” – Health Insurance Claim (HIC) number.Format accepted is (HIC#-SEE Begin Date-SEE EndDate). SEE stands for Small Employer Exception.Reference IdentificationM AN 1/50Member NameEntity Identifier Code Pg 61Entity Type QualifierName Last or Organization NameINDUSTRY: Subscriber Last NameName FirstINDUSTRY: Subscriber First NameName MiddleName PrefixName SuffixIdentification Code QualifierIdentification CodeINDUSTRY: Subscriber IdentifierMM ID 2/3M ID 1/1M AN 1/60PER040-PER01040-PER01Member Communication NumbersContact Function CodeCommunication Number QualifierOM ID 2/2O AN 1/60N3050-N301050-N301Member Residence Street AddressAddress Information Pg 67Address line 2MM AN 1/55O AN 1/55N4060-N401Member Residence City, State, ZipCity Name Pg 68MO AN 2/30060-N402StateO ID 2/2060-N403ZipO ID 3/15060-N404Country CodeO ID 2/2DMG080-DMG01080-DMG02Member DemographicsDate Time Period Qualifier Pg 70Date Time PeriodMM ID 2/3M AN on Guide for ANSI X12 834 – Version 005010X220A1“1L” - Insured or Subscriber“1” – PersonM AN 1/35O AN 1/25O AN 1/10O AN 1/10M ID 1/2M AN 2/80“34” Social Security NumberMust be numeric, 9 digits“IP” – Insured Party“EM” Electronic Mail“EX” Telephone Extension“FX” Facsimile“HP” Home Phone Number“TE” Telephone“WP” Work Phone NumberFor International Address please send defaultvalue ‘XXX’For International Address please send defaultvalue ‘XX’For International Address please send defaultvalue ‘NONUS’For International Address please send appropriatecode for the country“D8” (CCYYMMDD)Member Birth Date14 of 20

HIPAA FieldPositionSegment ID080-DMG03080-DM04HIPAA Data Element Name and PageNumber from Implementation GuideAttributesValid Values and CommentsGender CodeMarital Status Code (optional)M ID 1/1O ID 1/1“F”- Female, “M”- Male, “U” – Unknown“B” Registered Domestic Partner“D” Divorced“I” Single“M” Married“R” Unreported“S” Separated“U” Unmarried (Single or Divorced or Widowed)This code should be used if the previousstatus is unknown.“W” Widowed“X” Legally Separated2200DSB200-DSB01Disability InformationDisability Type Code Pg 124OM ID 1/1200-DSB07Product or Service ID QualifierX ID 2/2200-DSB08Medical Code ValueINDUSTRY: Diagnosis CodeM AN 1/15DTP210-DTP01Disability Eligibility DatesDate/Time Qualifier Pg 126OM ID 3/3210-DTP02210-DTP03Date Time Period Format QualifierDisability Eligibility DateM ID 2/3M AN 1/352300HD260-HD01260-HD03Health CoverageMaintenance Type Code Pg 128Insurance Line CodeMM ID 3/3M ID 2/3260-HD05260-HD05Plan Coverage DescriptionCoverage Level CodeO 1/50O ID 3/3DTP270-DTP01Health Coverage DatesDate/Time Qualifier Pg 131MM ID 3/3270-DTP02Date Time Period Format QualifierM ID 2/3270-DTP03Date Time PeriodINDUSTRY: Coverage PeriodM AN 1/35Companion Guide for ANSI X12 834 – Version 005010X220A1“1” Short Term Disability“2” Long Term Disability“3” Permanent or Total Disability“4” No Disability“DX” - ICD-9 Diagnosis“ZZ” – ICD-10 Diagnosis“585” - The only allowed valueUse DSB08 to indicate if the reason for disability isEnd Stage renal Disease (ESRD).“360” Disability Begin“361” Disability End“D8” - Date Expressed in Format CCYYMMDD“030” Audit or Compare“HLT” – Health. Includes both hospital andprofessional coverage“VIS” – Vision“DEN” - Dental“FAM“ – Family“IND” – Individual“ECH” – Employee and Children“348” Benefit Begin. This is the effective date ofcoverage. This code should always be sent whenadding coverage.“349” Benefit End. To cancel coverage which wasnot intended to be active, use benefit end dateequal to the benefit begin date.“543” Last Premium Paid Date / Hold Date“D8” Date Expressed in Format CCYYMMDD“RD8” Date Expressed in Range CCYYMMDD CCYYMMDD15 of 20

HIPAA FieldPositionSegment ID2310NM1320-NM101HIPAA Data Element Name and PageNumber from Implementation GuideAttributesProvider NameEntity Identifier Code Pg 140OM ID 2/3320-NM102Entity Type QualifierM ID 1/1320-NM103Name Last or Organization NameINDUSTRY: Subscriber Last NameName FirstINDUSTRY: Subscriber First NameName MiddleName PrefixIdentification Code QualifierO AN 1/35Identification CodeINDUSTRY: Subscriber IdentifierM AN 2/80Coordination of BenefitsPayer Responsibility Sequence NumberCode Pg 150OM ID 1/1M AN 1/50400-COB03Reference IdentificationINDUSTRY: Insured Group or PolicyNumberCoordination of Benefits CodeRANK – Only submit COB information that isPrimary to MagnaCare“P” Primary“S” Secondary“T” Tertiary“U” UnknownCOB policy number when it is availableM ID 1/1“1” Coordination of BenefitsREF405-REF01405-REF02Additional COB IdentifiersReference Identification QualifierReference IdentificationOM ID 2/3X AN 1/30’SY’ only. (A6-EIN deleted from 5010)COB Policy Nu

Implementation Guides, are intended to be compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Im