Oracle Enterprise HCM HIPAA Implementation

Table of Contents:
Overview..................................................................................................................................................2
Design Approach.................................................................................................................................2
Glossary...............................................................................................................................................3
Provider/Vendor Changes........................................................................................................................4
Benefit Plan Changes...............................................................................................................................4
EDI 834 Transaction Map Table..............................................................................................................5
Enrollment Snapshot Options..................................................................................................................7
EDI Trading Partners...............................................................................................................................8
Create HIPAA EDI 834 File Run Control..............................................................................................11
Miscellaneous File Changes..................................................................................................................14

289646641.doc

Oracle Proprietary and Confidential

Overview
The current HIPAA 834 implementation, based off of the ANSI Implementation Guide, is only available as a full-file and
has very little vendor-specific customizations available. There is a high demand for the creation of the HIPAA file on an
Update only basis, as recommended by the guide. In addition, customers have been requesting a wide range of changes to
the process to accommodate vendor-specific variations.
The HIPAA 834 file creation process has been modified to provide Update-only file capabilities and to accommodate many
of the variations that have been requested by customers. The changes made maintain overall compliance with the ANSI
format and refrain from Vendor-specific, non-conforming implementations.

Design Approach
Since this is designed as a posting, the approach taken is one that provides the minimal functionality required with a minimal
impact and risk for the customers. To determine the minimum requirements, some assumptions and limitations have been
made in the design of this functionality. They are the following:
-

All changes will be compliant with the ANSI 834 Implementation Guide (Benefit and Enrollment Maintenance 834
ASC X12N 834 (004010X095).

Due to technical limitations of the 8.0 and 8.3 software, only GA releases 8.8 SP1 and beyond will support this new
functionality

Only changes in personal data that can be tracked using effective dating will be supported on the update only file.
This means that not all dependent changes, such as a dependent address change, will be included in the 8.8 SP1
modifications, but they will be included in the 8.9 modifications (and beyond). Refer to a more detailed table of
changes that will trigger an update to be sent on Page 13.

In the Update file, all changes made to Benefit information will be included based on the election date of the change
and the date range of the update file created.

Whenever any member of a family has a change, records for the subscriber and all members of the family will be
included in the update file, potentially including records for members with no changes.

If multiple changes are made to the same member (or his family) within the date range of the update file, the most
recent data for the members will be sent in the file.

289646641.doc

Oracle Proprietary and Confidential

Glossary
HIPAA - Health Insurance Portability and Accountability Act of 1996.
ANSI - American National Standards Institute.
EDI Electronic Data Interchange.
X12 - American National Standards Institute Accredited Standards Committee electronic data interchange standard.
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.
Payer/Insurer - The payer is the party that pays claims and/or administers the insurance coverage, benefit, or product. A
payer can be an insurance company; Health Maintenance Organization (HMO); Preferred Provider Organization (PPO); a
government agency, such as Medicare or Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); or
another organization contracted by one of these groups.
Participant or member or insured - An individual associated with an enrollment. These individuals can be subscribers
(usually employees), or covered dependents.
Subscriber - The subscriber is an individual eligible for coverage because of his or her association with a sponsor. Examples
of subscribers include the following: employees, union members, and individuals covered under government programs, such
as Medicare and Medicaid.
Dependent - A dependent is an individual who is eligible for coverage because of his or her association with a subscriber.
Typically, a dependent is a member of the subscribers family.
External Trading Partner (receiver) Entity receiving the 834 transaction set transmission.
Internal Trading Partner (sender) Entity sending the 834 transaction set transmission.
Implementation Guide - Initial Data Requirements, ASC X12.834 Implementation Guide (X095.PDF and X095A1.PDF)
document, mentioned above.

289646641.doc

Oracle Proprietary and Confidential

Provider/Vendor Changes
The Group Number field has been expanded from 10 characters to 30 characters on the Provider/Vendor table. The Group
Number value is transmitted in the HIPAA file and supports the expanded length.
Example: (field affected is highlighted in red)
REF*1L*123146785678~
Navigation: Set Up HRMS > Product Related > Base Benefits > Plans and Providers > Provider/Vendor Table

Benefit Plan Changes

The Benefit Plan Table includes two new fields.

EDI Plan Coverage Description

The EDI Plan Coverage Description field (A/N 50) has been added to the Benefit Plan Table as an optional field. Any value
that is entered in the field is included in the HIPAA file in position HD04 in loop 2300.

EDI Insurance Line Code

An EDI Insurance Line Code drop-down prompt field has been added to the Benefit Plan table and contains appropriate
values based on the Plan Type and Effective Date of the Benefit Plan. This field, in conjunction with the EDI Transaction
Mapping table values, is used to populate the HD03 value in loop 2300.
Examples: (field modified are highlighted in red)
Current HD segment:
HD*030**HLT**EMP~
HD Segment with Insurance Line Code value (= Health Maintenance Org) and Plan Coverage Desc. value (= Californias
Best Health Maintenance Organization) included:
HD*030**HMO*Californias Best Health Maintenance Organization*EMP~
Navigation: Set Up HRMS > Product Related > Base Benefits > Plans and Providers > Benefit Plan Table

289646641.doc

Oracle Proprietary and Confidential

EDI 834 Transaction Map Table

Several changes have been made to the EDI 834 Transaction Map Table.

Marital Status
Marital Status has been added as a field to the table and several existing status mappings are delivered as seen below. The
Mapped field value for the Marital status will be included in the DMG04 in loop 2100A for the Subscribers only. These
mapped field values can be edited as needed.
Examples: (new fields are highlighted in red)
Current DMG segment for an Employee:
DMG*D8*19650313*M~
DMG Segment for an Employee with Marital Status (= Married) included:
DMG*D8*19650313*M*M~
Navigation: Set Up HRMS > Product Related > Base Benefits > EDI 834 Transaction Map Table

Plan Type
Additional Plan Type mappings have been added to the table to accommodate the new EDI Insurance Line Code values as
described in the Benefit Plan Changes section above. A snapshot of a few of the additional mapping values can be seen
below. These mappings can be modified as needed.
Navigation: Set Up HRMS > Product Related > Base Benefits > EDI 834 Transaction Map Table

289646641.doc

Oracle Proprietary and Confidential

Default EDI Code

A Default EDI Code checkbox has been added to the Plan Type mappings as shown below. Each Plan Type will have one
default EDI code based on the current default HD03 value used in the HIPAA file (eg HLT for Plan Type 10). If a Benefit
Plan does not have an EDI Insurance Line Code value, the mapped value for the plan type that is flagged as the Default
EDI Code is used as the value in the HIPAA file.
Navigation: Set Up HRMS > Product Related > Base Benefits > EDI 834 Transaction Map Table

289646641.doc

Oracle Proprietary and Confidential

Enrollment Snapshot Options

The existing Include Implied Terminations checkbox was renamed to Include Implied Employee Terminations on the
Enrollment Snapshot Options page. This functions as it did before. The change was made to make it clear that it only referred
to implied Employee terminations.
A new checkbox has been added named Include Implied Dependent Terminations. When selected, the system creates
termination records for dependents in the snapshot and reports them in the HIPAA file when there is a termination for an
Employee that also terminated the dependent or when a new coverage row has been added for an Employee and a dependent
that was previously covered has been dropped from coverage.
Note: Include Implied Dependent Terminations checkbox functionality only works when the Include Implied Employee
Terminations checkbox is also checked.
Example: Spouse record with a termination date of 2/1/2000
INS*N*01*030*XN*A*E****N~
REF*0F*KU0080~
REF*1L*1473~
DTP*303*D8*20000108~
NM1*IL*1*Sakata*Kien****34*333784518~
PER*IP**HP*9256947980~
N3*251 E. River Street~
N4*Savannah*GA*31414*USA~
DMG*D8*19510307*M~
HLH*U~
HD*030**HLT~
DTP*349*D8*20000201~
Navigation: Set Up HRMS > Product Related > Base Benefits > Enrollment Snapshot Options

Note: The Include Original Enrollment Date functionality applies to both Employees and Dependents. When unchecked,
the latest Coverage Begin Date value is populated in the DTP segment of Loop 2300 for all members. When checked, the
Original Enrollment date in the Benefit plan for all members is used to populate this value. This functionality has not
changed.

289646641.doc

Oracle Proprietary and Confidential

EDI Trading Partners

Several additional fields have been added to the EDI Trading Partners setup page. Their functionality is detailed below.
Navigation: Set Up HRMS > Product Related > Base Benefits > EDI Trading Partners

Application Receivers Code

An Application Receivers Code field (A/N 15) has been added to the EDI Trading Partners page. This value is used to
populate the GS03 field and defaults to the External Partner ID value. The External Partner ID will continue to be used in the
ISA segment as appropriate.

Application Senders Code

An Application Senders Code field (A/N 15) has been added to the EDI Trading Partners page. This value is used to
populate the GS02 field and defaults to the Internal Partner ID value. The Internal Partner ID will continue to be used in the
ISA segment as appropriate.

Examples: (fields modified are highlighted in red)

ISA & GS segments using the defaults External ID = 1234567890 & Internal ID = 0987654321:
ISA*00*
*00*
*ZZ*0987654321 *ZZ*1234567890 *050714*1143*U*00401*000000011*0*P*:~
GS*BE*0987654321*1234567890*20050714*1143*1*X*004010X095A1~

289646641.doc

Oracle Proprietary and Confidential

ISA & GS segments with External ID = 1234567890, Internal ID = 0987654321, App Senders Code = 22222 & App
Receivers Code = 33333:
ISA*00*
*00*
*ZZ*0987654321 *ZZ*1234567890 *050714*1143*U*00401*000000011*0*P*:~
GS*BE*22222*33333*20050714*1143*1*X*004010X095A1~

Alternate Transaction Set Identifier Code Group Number

The Transaction Set Identifier Code that is sent in the BGN segment (BGN02) is built by concatenating the EDI External
Partner ID, Interchange Control Number and Transaction Set Control Number.
An Alternate Transaction Set Identifier checkbox and a Group Number field (A/N 15) have been added to the EDI Trading
Partner page. When selected, an Alternate Group Number is required to be entered. This value is used in place of the External
Partner ID when creating the concatenated Transaction Set Identifier Code value.

Examples: (field affected is highlighted in red)

If left unchecked and field is unpopulated & External Partner ID = 1234567890:
BGN*00*1234567890 000000011 0001*20050714*1143*PS***4~
If checked and field is populated with the value = 121212 & External Partner ID = 1234567890:
BGN*00*121212 000000011 0001*20050714*1143*PS***4~

Security Password
A Security Password Required checkbox and a Password field (A/N 10) have been added to the EDI Trading Partner page
to indicate security information in the HIPAA file. If Security Password Required is selected, a 10 character password value
is required. If this information is entered, the ISA03 value is set to 01 in the ISA segment and the Password value is sent in
position ISA04.

Examples: (fields modified are highlighted in red)

ISA segment using the defaults:
ISA*00*
*00*
*ZZ*654321
*ZZ*123456

*050714*1143*U*00401*000000011*0*P*:~

ISA segment with Password checked & value = AABB123456:

ISA*00*
*01*9898989898*ZZ*654321
*ZZ*123456

*050714*1143*U*00401*000000011*0*P*:~

Master Policy Number

A Master Policy Number field (A/N 30) has been added. When a value is entered in this field, a new REF segment
(Transaction Set Policy Number) with a Reference ID Qualifier of 38 is sent in the Header of the HIPAA file and includes
the Master Policy Number value.

289646641.doc

Oracle Proprietary and Confidential

Examples: (new segment is highlighted in red)

If Master Policy Number = 999998888877777, then the header segment =
BGN*00*123456 000000011 0001*20050714*1143*PS***4~
REF*38*999998888877777~
N1*P5*Global Business Institute*FI*994123456~

Subscriber Number
A Subscriber Number option has been added to the EDI Trading Partner page to indicate the value that is sent in REF02 of
the REF*0F segment in loop 2000. Currently, the Subscribers EmplID value is sent in the HIPAA file. When the Subscriber
Number option is set to SSN, the HIPAA process will use the Social Security Number (NID) of the Subscriber instead of
the EmplID. The records for dependents will also use the Subscribers SSN for the REF02 value.
Note: If SSN has been selected and the Subscriber does not have a Social Security Number (NID), the file will use the
EmplID for that Subscriber and his/her members records.

Examples: (field affected is highlighted in red)

Current functionality using the EmplID:
INS*Y*18*030*XN*A*E**TE**N~
REF*0F*KU0115~
Modified functionality using the SSN of the Member:
INS*Y*18*030*XN*A*E**TE**N~
REF*0F* 556754398~

289646641.doc

Oracle Proprietary and Confidential

10

Create HIPAA EDI 834 File Run Control

Multiple fields have been added to the HIPAA EDI Run Control. Their functionality is detailed below.
Navigation: Benefits > Interface with Providers > Create HIPAA EDI 834 File

File Effective & File Enrollment Dates

Two new date fields have been added to the HIPAA EDI Run Control. When either of the dates have been entered in the Run
control, the corresponding DTP segment(s) is created and sent in the file. The File Effective Date value is sent in a DTP
segment with the Date Qualifier of 007. The File Enrollment Date value is sent in a DTP segment with the Date Qualifier
of 382.

289646641.doc

Oracle Proprietary and Confidential

11

Examples: (new segments are highlighted in red)

If File Effective date = 1/22/2006, and File Enrollment date = 2/1/2006, then the header segment =
BGN*00*123456 000000011 0001*20050714*1143*PS***4~
DTP*007*D8*20060122~
DTP*382*D8*20060201~
N1*P5*Global Business Institute*FI*994123456~
.

Acknowledgement Requested
In the ISA segment of the file, there is an Acknowledgement Requested option (ISA14) with valid values of either 0 or 1.
Currently, the system inputs a 0. An Acknowledgement Requested checkbox has been added to the HIPAA EDI Run
Control to indicate if an acknowledgement is requested. When this checkbox is selected, the ISA14 value is sent as a 1
instead of a 0.

Examples: (field affected is highlighted in red)

ISA Segment with No Acknowledgement requested (checkbox unchecked):
ISA*00*
*00*
*ZZ*654321
*ZZ*123456
*050714*1143*U*00401*000000011*0*P*:~
ISA Segment with Interchange Acknowledgement requested (checkbox checked):
ISA*00*
*00*
*ZZ*654321
*ZZ*123456
*050714*1143*U*00401*000000011*1*P*:~

Test File
In the ISA segment of the file, the ISA15 (Usage Indicator) value is a fixed value of P (Production) by default. A Test File
checkbox has been added to the Run Control that indicates file is to be used as a Test file instead of a Production File. When
this is selected, the ISA15 value is sent as a T instead of a P.

Examples: (field affected is highlighted in red)

ISA Segment for a Production file (checkbox unchecked):
ISA*00*
*00*
*ZZ*654321
*ZZ*123456

*050714*1143*U*00401*000000011*0*P*:~

ISA Segment for a Test file (checkbox checked):

ISA*00*
*00*
*ZZ*654321
*ZZ*123456

*050714*1143*U*00401*000000011*0*T*:~

File Type Functionality

A File Type drop-down field has been added to the EDI Run control. The three values and their functionality are the
following:
Full File Audit: This File Type creates a file that contains Member records for all members, including terminations. This file
type is the default and is similar to the files created prior to the file type options.
Full File Replacement: This file type creates a file that contains current Member records only as of the date of the file. All
terminated members are dropped from the file. This file is typically used in conjunction with Update Only files and is sent to
verify synchronization between the two systems.

289646641.doc

Oracle Proprietary and Confidential

12

Update Only File: This file type creates a file that contains only those records where changes have occurred to either the
Subscriber or any of his/her dependents records that are relevant to the vendor and can be tracked in HRMS through the use
of effective dates. These include changes such as adding coverage, changing a coverage code, an address change, a PCP
change, a change in the covered dependents, a change in job status (from active to retiree), and terminations. Changes made
to the job record that have no effect on Health benefits (such as a salary change) are not included in the file.
When the Update Only File file type is selected, the From Date and To Date fields appear and are required. The To Date
will automatically be set to the snapshot As Of Date. This date range will filter the change records to only include those
member records that had changes within the date range. Benefit enrollment records will use the Election Date as the date
that the change was made. This will allow for backdated changes in addition to future changes to be included in the file.
Note: Any changes that are done in Correct History mode will not automatically trigger an update to be sent. The update
will only be sent for that record if and when the Election date (for Benefits changes) or the Effective Date (for Job and
Personal Information changes) for the record falls within the date range of the Update File.
Whenever the subscriber or any member of a subscribers family has a change, the complete record(s) for all relevant
members of the family will be sent in the file (including members with no changes). The members data sent in the file will
always be the data that is effective as of the date of the Benefits Snapshot, even if multiple changes have been made to a
members record within the date range.
The BGN and the INS segments will be modified to indicate the file type and the type of change made to the record as
appropriate.

The following table includes changes in Benefits, Job and Personal data that will or will not be included in an Update only
file per release. The differences in the two releases are due to the effective-dating logic for dependents that is included in 8.9.
Benefits Data

Job Status
Personal Data

289646641.doc

Changes included in Update file

New Enrollments
Coverage Code
Benefit Plan
Primary Care Physician (PCP)
Covered Dependents
Plan Terminations
Job Termination, Term with Benefits, Term with Pay
Hire, Rehire
Retirement, Retirement with Pay
Employee Address
Employee Medicare Status
Employee Name Change
Employee Marital Status
Employee Gender
Employee Smoker Status
Employee Birth Date
Dependent Student Status
Dependent Address
Dependent Medicare Status
Dependent Name Change
Dependent Gender
Dependent Smoker Status
Dependent Birth Date

Oracle Proprietary and Confidential

8.8
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
N
Y
N
N
N
N

8.9
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
Y
Y
Y
N
Y
N

13

Miscellaneous File Changes

Suppression of HD and DTP Termination Row (under certain conditions)
Currently, if an Employee changes their Benefit Plan enrollment to a new Benefit Plan administered by the same Vendor, two
HD and DTP rows appear in the file, one with the new enrollment and one with the termination of the prior Benefit Plan.
The output file has been modified to suppress the HD and DTP termination row for the old plan when the Vendor and the
Group Number for both the old and new Benefit Plans are identical. If the Vendor and/or Group Numbers are different for the
two Benefit Plans, then the HD and DTP rows for both the new enrollment and the termination will appear in the file.
Examples: (fields affected is highlighted in red)
HD and DTP segments for Employee who changed his Vision plan to a new plan with the same Vendor and a different Group
Number:
HD*021**VIS**E5D~
DTP*348*D8*20000201~
REF*1L*123456~
HD*024**EVO**E5D~
DTP*349*D8*20000201~
REF*1L*123456~
HD and DTP segments for Employee who changed his Vision plan to a new plan with the same Vendor with the same Group
Number:
HD*021**VIS**E5D~
DTP*348*D8*20000201~
Note that there is no termination row for the old plan

Suppression of the Country value USA

The HIPAA process will now only transmit a Country value in the N404 position if it is something other than USA.
Examples: (field affected is highlighted in red)
N4 segment with USA suppressed:
N4*Jackson*MS*39215~
N4 segment for an address in Canada:
N4*Toronto*ON*M6N1K9*CAN~

Suppress the Student Status Code

The Student Status code will only be sent for non-spouse, non-handicapped, non-domestic partner adult dependents equal to
or over the dependent age limit for the Benefit Program as defined in the system. If the dependent is equal to or greater than
the dependent age limit, is not a spouse or a domestic partner adult, and is non-handicapped, then the value of F (Fulltime
Student) will be sent in INS09 if the student flag is Yes as of the date of the file, otherwise, the value will be N (Not a
Student).
If the dependent is under the dependent age limit, is a spouse, is a domestic partner adult, or is handicapped, then no value
will be sent in the student status code field (INS09).
Examples: (field affected is highlighted in red)
INS segment for a child dependent that is under the age limit Note that there is no Student Status code:

289646641.doc

Oracle Proprietary and Confidential

14

INS*N*19*030*XN*A*E****N~

DMG*D8*19970121*M~

Note that there is no Student Status Code here

INS segment for a child dependent that is over the dependent age limit & is a Student:
INS*N*19*030*XN*A*E***F*N~

DMG*D8*19850121*M~

Additional Member Level Dates sent in DTP segments

Additional DTP segments will be created and sent in loop 2000 for Members as appropriate for the following new Date/Time
Qualifiers:
Retirement 286

Hire 336

Medicare Begin 338

Medicare End 339

Either the Hire or Retirement DTP segments will be included for Subscribers when appropriate. Either the Medicare Begin or
End DTP segments will be sent for both Subscribers and their members when appropriate. The Medicare Begin date sent is
determined by the effective date of the row where one or more of the Medicare checkboxes is selected for the member. The
Medicare End date sent is calculated as the date immediately prior to the effective date of the latest row that has been added
with the Medicare checkboxes unchecked
Examples: (new segments are highlighted in red)
If Hire date = 2/15/1999, then Member segments =
INS*Y*18*030*XN*A*E**TE**N~
REF*0F*KU0115~
REF*1L*121~
DTP*303*D8*20060201~
DTP*336*D8*19990215~
NM1*IL*1*Mapin*George*N*Mr**34*556754398~

If Hire date = 2/15/1999, and Retire Date = 2/1/2006, then Member segments =
INS*Y*18*030*XN*A*E**TE**N~
REF*0F*KU0115~
REF*1L*121~
DTP*286*D8*20060201~
DTP*303*D8*20060201~
NM1*IL*1*Mapin*George*N*Mr**34*556754398~

Navigation: Benefits > Employee/Dependent Information > Personal Information

289646641.doc

Oracle Proprietary and Confidential

15

If Medicare Begin date = 1/1/2006, then Member segments =

INS*Y*18*030*XN*A*E**TE**N~
REF*0F*KU0115~
REF*1L*121~
DTP*303*D8*20060201~
DTP*338*D8*20060101~
NM1*IL*1*Mapin*George*N*Mr**34*556754398~

If Medicare End date = 1/31/2006 (date prior to row with no Medicare boxes selected), then Member segments =
INS*Y*18*030*XN*A*E**TE**N~
REF*0F*KU0115~
REF*1L*121~
DTP*303*D8*20060201~
DTP*339*D8*20060131~
NM1*IL*1*Mapin*George*N*Mr**34*556754398~

Medicare checkboxes for dependents:

Navigation: Benefits > Employee/Dependent Information > Update Dependent/Beneficiary

289646641.doc

Oracle Proprietary and Confidential

16