Benefits Enrollment
Recommendation, 2007 April 15
Editors:
Suneel Mendiratta, Employease
Kelly Cohen, Hewitt Associates
Kim Bartkus, HR-XML Consortium
Schema Editors:
Dan Diman, eBenX
Kim Bartkus, HR-XML Consortium
Contributors:
Members of the Benefits Enrollment workgroup
Copyright © 2007, HR-XML Consortium, Inc.
Abstract
This document describes an XML Schema that supports the transfer of benefits enrollment data between organizations (for example, a benefits administrator and an insurance carrier). This schema is part of the HR-XML Consortium effort to define an XML vocabulary to support business transactions in the Human Resource domain.
Table of Contents
2 Supported Business Processes
3.4 The BenefitsAdiminstrativeAffiliate Element
3.6.1 The Coordination of Benefits Info Global Type
3.6.2 The Dependent Data Global Type. 19
3.6.3 The Coverage Global Type
3.6.4 The USTierCoverage Global Type. 24
3.6.5 The USSpendingAccountCoverage Global Type
3.6.6 The USRateBasedCoverage Global Type
3.6.7 The EmploymentData Global Type. 44
3.6.8 The MedicareData Global Type
3.6.9 The MedicaidData Global Type
3.6.10 The HIPAAData Global Type
3.6.11 The PersonData Global Type
3.6.12 The LanguageData Global Type
3.6.13 The CarrierData Global Type
3.6.14 The IdCardData Global Type
3.6.15 The SchoolData Global Type
4 Implementation Considerations
4.2 Update versus Replacement File Reporting
4.3 Complete Family Reporting versus Individual Changes Only
4.4 Correcting Person Identifier, Name and Demographic Data
4.5 Coverage Level for Dependents
4.6 COBRA Eligible; Not Enrolled
4.7 COBRA Enrolled; Premium Not Paid
4.8 COBRA Enrolled; Premium Paid
4.9 Receiving System Derives Group or Policy Numbers
4.12 Originating SSN for Surviving Dependents
4.13 Spending Account Enrollments
4.14 Healthcare Spending Accounts (HSAs)
4.15 Dependent Life Enrollments
4.16 Optional Information – not known by source system
4.17 Required Date Information – not known by source system
4.18 Current vs. Historical Tier Coverage
5 Appendix A - Document Version History
6 Appendix B – Related Documents
7 Appendix C - Business and Life Events
8 Appendix D – Benefit Enrollment Glossary
9 Appendix E – Component Enumerations
10 Appendix F - Messaging Considerations
1 Overview
1.1 Objective
This document describes HR-XML’s Enrollment schema, which is designed to support the transfer of benefits enrollment data between organizations (see Section 2, Supported Business Processes). A second document, Enrollment Reference Examples (see Appendix B – Related Documents), contains annotated examples illustrating how the specification can be used.
The current specification is largely focused on employee
benefit plan enrollment scenarios within the
1.1.1 Changes in This Version
This version of the HR-XML Enrollment specification includes the following changes:
1. Gave names to certain anonymous types. This allows for better modularization, reuse, and handling by class generation tools.
2. Added “HSAVendor” element to “TierCoverage”.to better support enrollments in Healthcare Spending Account (HSA) programs. See Section 4.14, Healthcare Spending Accounts (HSAs) and Section 3.6.4, USTierCoverage Global Type. HSAVendorType extends the existing CarrierData data type. In addition to OrganizationName, OrganizationCode, and ContactMethod available in CarrierData, the HSAVendorType adds a UseDefaultAccountSponsor and a SignatureDate. The UseDefaultAccountSponsor is a Boolean that may be used to indicate whether the subscriber has elected the health plan’s default HSA vendor. SignatureDate indicates that the benefits administrator has obtained and has on file, the beneficiary’s signed election of the designated HSA vendor.
3. Added “Health Reimbursement Account” to existing enumerated SpendingAccountCoverage types. Existing enumerations were: FSA Health Care and FSA Dependent Care.
4. Added optional PlanStartDate and PlanEndDate elements under SpendingAccountCoverage. These elements are intended to be used when finer-grained “plan year” information is required. This might be necessary to handle special circumstances such as when the plan year may be less than a full year.
5. Within ContributionData, made the following changes:
· Made GoalAmount element optional (not relevant for all spending account coverage types)
· Added optional StartDate (LocalDateType). This is the date on which contribution changes become effective.
· Added optional FirstPayrollDate (LocalDateType). This would be an indication of the first payroll date on which contributions would start.
6. Added an optional AutoReimbursementIndicator element. This has enumerated values of “all”; “none”; and “byClaim”.
1.1.2 Domain Issues
Systems that store benefits enrollment data belong to many different types of organizations. These systems may belong to employers, third party administrators (TPAs), benefit suppliers/vendors, or other parties involved in the administration or provision of benefits to employees or other human resources. There exists significant variation in the capabilities, the structural organization of data, and (beyond a certain core set) the individual data elements stored in such systems. By solicitation of input from a cross section of organizations which store benefits enrollment data, the Benefits Enrollment schema aims to provide low barriers to adoption of this standard for many disparate system types while providing a rich structure capable of supporting complex transactions.
Benefits provided by organizations to their employees or other human resources are of many types: medical insurance, flexible spending accounts, life insurance, short term disability insurance, 401(k), employee stock purchase and many others. Furthermore, the universe of benefits is not static: it grows as new products enter the market. The schema design must take these domain facts into account; the schema must be easy to extend to new benefit types and must support a wide range of benefit types.
Many underlying business events and situations affect the enrollment of human resources in benefits. These events and situations may originate with the individual (birth, marriage, death, change of address, etc.), the organization (merger, location closure, new product offering, etc.) or another entity (government regulation change, union certification, etc.).
1.1.3 Business Reasons
1.1.3.1 Why should there be a standard?
The provision of benefits by employers to employees and their dependents is a large industry and accounts for millions of dollars. The communication of individuals enrolled in benefits and the data which describe their enrollments determines how and when money changes hands as well as ensures that subscribers get the services in which they have enrolled when they need them. The workgroup envisions a day when reliable, low-overhead electronic connections between plan sponsors, TPAs, insurers, payers, and other trading partners allow cost savings for all parties and improve the quality, cleanliness, and delivery time of enrollment data. In turn, the accuracy of payments made for the provision of benefits and the quality of the benefit experience for the subscriber is improved. To that end, the workgroup advances an XML standard for the exchange of enrollment information. Such a standard will facilitate the creation of an environment where it is possible for trading partners to quickly create durable, reliable electronic connections. Furthermore, work done to create one trading partner connection is re-usable with subsequent trading partners. These benefits translate into reduced cost to create a new connection and reduced costs to maintain and run an existing connection.
1.1.3.2 What do I have to gain as an employer/HRIS solution provider/benefits provider from adopting this standard?
The goal of this standard is to make it possible for adopters to use electronic media for the reliable, low cost transmission of benefits enrollment data, and to commoditize electronic trading partner connections. The value proposition of any such electronic communication channel lies in how the trading partners use this capability to improve the efficiency and capability of their shared business processes. To support this, the standard ensures consistency of implementation across trading partners while still supporting the flexibility that different types of trading partners might require to achieve their business goals. The end result of this effort is reduced entry cost, reduced maintenance cost, and greater consistency of implementation across trading partners.
1.2 Scope
The Benefits Enrollment schema supports enrollment and maintenance of human resources in tier-based coverage (such as medical, dental and vision), spending accounts (more commonly known as flexible spending accounts (FSA)), rate-based coverage (such as life, short term disability, and long term disability) and stock purchase plan coverage.
The Benefits Enrollment team recognizes that the Benefits Enrollment schema and the TierCoverage element in particular represent American benefit enrollment models. As the Benefits Enrollment team recruits international members, it plans to release subsequent versions with either a modified TierCoverage element or multiple Coverage elements representing other countries' benefit enrollment requirements. Until that time, the data type, 'USTierCoverage' best models American benefit enrollment requirements.
1.2.1 Major Components
The major components of an enrollment transaction payload are:
· Subscriber
· Dependent
· Coverage
2 Supported Business Processes
2.1 Trading Partner Roles
The Benefits Enrollment schema supports the exchange of enrollment information between trading partners. Trading partners may be large employers, HR software vendors, third party administrators, or insurance carriers.
The role of the trading partner within the context of the Benefits Enrollment schema is to communicate and/or receive benefit enrollment information as it relates to a subscriber or dependent.
2.2 Business Process Name
2.2.1 Summary
The Benefits Enrollment schema supports the exchange of enrollment information between trading partners. Typical uses of the schema are described below and are depicted in the following diagram:
· The exchange of information between a large employer and third party administrator to pass enrollment information for all coverages across all carriers.
· The exchange of information between a large employer (using HR software) and an insurance carrier to pass enrollment information for that carrier/administrator.
· The exchange of information between a third party administrator and an insurance carrier to pass single or multiple employers’ enrollment information for that carrier.
2.2.2 Use Case Scenarios
Many employee life and business events and employer events drive enrollment-related events. Version 2.1 of the Benefits Enrollment schema supports the exchange of tier-based, spending account, and rate-based enrollment information initiated by these events. Section 7 (Appendix C - Business and Life Events) lists the specific events, categorized as enrollment changes, personal life events, work life events, data changes, or organizational events.
2.2.3 Diagrams
The marriage life event provides a specific example for communicating enrollment-related information between entities. This section describes the specific processes. The actual XML examples are found in the Enrollment Reference Examples document (see Appendix B – Related Documents).
Upon a marriage event, a Person elects to add his/her spouse to medical coverage. The Person sends enrollment to the Employer’s Human Resources department, Administrator, or Carrier. Any of these three recipients can then inform the other two, depending on the division of administrative responsibilities.
2.3.3.1 Marriage Life Event Diagram
3 Schema Design
3.1 Component Schemas
The Enrollment schema is componsed of a number of component schemas. These schemas are detailed below.
o Enrollment/EnrollmentTypes.xsd. This a collection of reusable types used within the enrollment schema.
o Enrollment/Localizations.xsd. This schema would be edited by implementers to include the appropriate local content. This schema will become more relevant as additional local content is added.
US-Only Components
o Enrollment/US/USLocalizations.xsd. This contains certain components related to US social insurance programs and mandates (e.g., Medicare, Medicaid, “HIPAA”, “COBRA”).
o Enrollment/US/USRateBasedCoverage.xsd. This contains components related to rate-based coverages, such as life and accident insurance.
o Enrollment/US/USSpendingAccountCoverage.xsd.
This contains components related to spending account coverages, such as
“flexible spending accounts,” a type of account given certain
preferences under
o Enrollment/US/USTierCoverage.xsd.
Stock Purchase Plan Coverage Schema
o Stock/StockPurchasePlanCoverage.xsd
Separate documentation for the Stock Purchase Plan Coverage Schema is available in distribution packages that can be downloaded from the HR-XML website (http://www.hr-xml.org).
Cross-Process Objects
o CPO/ContactMethod.xsd
o CPO/PostalAddress.xsd
o CPO/OnlineAddress.xsd
o CPO/TelcomNumber.xsd
o CPO/PersonName.xsd
o CPO/EntityIdType.xsd
Note that documentation for CPO schemas is available in distribution packages that can be downloaded from the HR-XML website (http://www.hr-xml.org). Also see, Appendix B – Related Documents.
3.2 Overview
Below is a high-level diagram of the Benefit Enrollment schema.
3.3 The Enrollment Element
The Enrollment element is the root of the Benefits Enrollment schema.
|
Elements and Attributes [Global types listed alphabetically in following table.] |
ContentModel* |
Definition |
|
/ |
transactionType xsd:restriction base: xsd:string
[Enumerations]: Change, Full |
Container for the benefits enrollment specification. |
|
/
Enrollment/ |
xsd:restriction base: xsd:string [Enumerations]: Change, Full |
In the
context of a batch transaction, specifies if it is a full or changed payload.
[BusinessRule(s): It is not intended as a processing instruction for
the receiving system. ] |
|
/
Enrollment/ |
- DateTimeType - |
Date file was created. |
|
/
Enrollment/ |
- xsd:string - |
Code
identifying the transaction originator, typically the sender's taxpayer |
|
/
Enrollment/ |
- xsd:string - |
Name of the transaction originator. |
|
/
Enrollment/ |
- LocalDateNkNaType - |
Date representing baseline for change data. |
|
/
Enrollment/ |
- xsd:string - |
Code
identifying the transaction's recipient typically the recipient's taxpayer |
|
/
Enrollment/ |
- xsd:string - |
Name of the transaction recipient. |
|
/
Enrollment/ |
- EntityIdType - S (0/1) |
An
identifier to tie the original transmission to the acknowledgement of that
transmission. |
|
/
Enrollment/ |
organizationName - xsd:string - required |
Contains information about the organization. |
|
/
Enrollment/ Organization/ |
- xsd:string - |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/ Enrollment/ Organization/ |
OrganizationName - xsd:string - C (1/1) |
High level container to describe plan administration. Annotation: These entities provide service to the Organization related to the organization's provision of benefits to subscribers. |
|
Enrollment/ Organization/ |
SubscriberType - xsd:string - S (1/1) |
Contains information about the person whose ability to enroll in benefits is based on his/her relationship to the organization. |
|
/ Enrollment/ Organization/ |
- EntityIdType - S (0/*) |
Unique identifier for the organization. It may be an internal identifier assigned by the sender. |
3.4 The BenefitsAdiminstrativeAffiliate Element
The BenefitsAdiminstrativeAffiliate element is an optional element containing information identifying the plan administrator.
|
Elements and Attributes [Global types listed alphabetically in following table.] |
ContentModel* |
Definition |
|
/
Enrollment/ Organization/ |
OrganizationName
- xsd:string - C
(1/1) |
High level container to describe plan administration. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
- xsd:string - C (1/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
- PersonNameType - C (1/1) |
The name of a person. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
xsd:restriction base: xsd:string [Enumerations]: Plan Sponsor, Insurer, Broker or Sales Office, First Party Administrator, Second Party Administrator, Third Party Administrator, Other Affiliate |
Describes
the role played by the BenefitsAdministrativeAffiliate. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
- xsd:string - S (0/1) |
An account number for an institution. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
- EntityIdType - S (0/1) |
A unique identifier used to reference the entity. The Id is associated with the higher level element. |
|
/
Enrollment/ Organization/ BenefitsAdministrativeAffiliate/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
3.5 The Subscriber Element
The Subscriber element is a required element containing information about the individual with an ability to enroll in the benefits program(s) based on a relationship with the Organization sponsoring the benefit program(s).
|
Elements and Attributes [Global types listed alphabetically in following table.] |
ContentModel* |
Definition |
|
/
Enrollment/ Organization/ |
SubscriberType
- xsd:string - S
(1/1) |
Contains information about the person whose ability to enroll in benefits is based on his/her relationship to the organization. |
|
/
Enrollment/ Organization/ Subscriber/ |
SubscriberTypeCode
- xsd:string - S
(1/1) |
Contains information describing the relationship between the subscriber and the Organization. |
|
/
Enrollment/ Organization/ Subscriber/ SubscriberType/ |
xsd:restriction base: xsd:string [Enumerations]: Employment, Survivorship, Dependent-only Coverage |
This code indicates why this individual can enroll in benefits provided by the organization. |
|
/
Enrollment/ Organization/ Subscriber/ SubscriberType/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
Enrollment/ Organization/ Subscriber/ |
IdentificationCode
- EntityIdType - S
(1/1) |
Provides a link from this subscriber to another subscriber. For use in elevated dependent situation such as survivorship. |
|
/
Enrollment/ Organization/ Subscriber/ OriginatingSubscriberData/ |
- EntityIdType - S (1/1) |
A unique identifier used to reference the entity. The Id is associated with the higher level element. |
|
/
Enrollment/ Organization/ Subscriber/ OriginatingSubscriberData/ |
- PersonNameType - S (0/1) |
The name of a person. |
|
/
Enrollment/ Organization/ Subscriber/ |
- PersonData - S (1/1) |
Contains various data about a person. |
|
/
Enrollment/ Organization/ Subscriber/ |
- CoverageType - S (1/1) |
Identifies
the type of coverage. |
|
/
Enrollment/ Organization/ Subscriber/ |
- EmploymentData - S (0/1) |
Container for all employment-related information as it relates to the person. |
|
/
Enrollment/ Organization/ Subscriber/ |
- HIPAAData - S (0/1) |
Health Information Portability and Accountability Act. Container for HIPAA related elements. |
|
/
Enrollment/ Organization/ Subscriber/ |
- MedicareData - S (0/1) |
Container for subscriber's Medicare information. |
|
/ Enrollment/
Organization/ Subscriber/ |
- MedicaidData - S (0/1) |
Container for subscriber's Medicaid information. |
|
/
Enrollment/ Organization/ Subscriber/ |
BenefitReportingType
- xsd:string - S
(1/1) |
High level container to describe the benefits-related reporting required. |
|
/
Enrollment/ Organization/ Subscriber/ BenefitReportingInformation/ |
- xsd:string - S (1/1) |
Indicates
the type of benefit reporting. |
|
/
Enrollment/ Organization/ Subscriber/ BenefitReportingInformation/ |
- xsd:string - S (1/1) |
Indicates the corresponding value of BenefitReportingType. |
|
/
Enrollment/ Organization/ Subscriber/ BenefitReportingInformation/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
Enrollment/ Organization/ Subscriber/ |
- CoordinationOfBenefitsInfoType - S (0/1) |
Contains information about other insurance coverage with which an insurer must coordinate payment. Contains an indicator of whether coordination of benefits is applicable and optionally the name of the other insurer and effective dating. |
|
- DependentDataType - S (0/*) |
The Dependent element (using the DependentDataType) is an optional child of the Subsriber element. It is a container for all information related to a Subscriber’s dependent. A Subcriber element may have from zero to an unlimited number of Dependent elements. |
3.6 Global Types
3.6.1 The Coordination of Benefits Info Global Type
Used by CoordinationOfBenefits element under both Subscriber and Dependent. Contains information about other insurance coverage with which an insurer must coordinate payment.
|
/ |
CoordinationOfBenefitsIndicator
- CoordinationOfBenefitsIndicatorTypesType - S (1/1) |
Contains information about whether a coordination of benefits situation exists. Optionally allows the inclusion of the name of the relevant insurer and effective dating. |
|
/
[CoordinationOfBenefitsInfoType]/ |
- CoordinationOfBenefitsIndicatorTypesType - S (1/1) |
Indicates whether there is other coverage with which payments must be coordinated. Enumerated values are: yes, no, and unknown. |
|
/
[CoordinationOfBenefitsInfoType]/ |
- xsd:string - S (0/1) |
The name of the insurer. |
|
/
[CoordinationOfBenefitsInfoType]/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins. |
|
/
[CoordinationOfBenefitsInfoType]/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. |
3.6.2 The Dependent Data Global Type
The Dependent element (using the DependentDataType) is an optional child of the Subsriber element. It is a container for all information related to a Subscriber’s dependent. A Subcriber element may have from zero to an unlimited number of Dependent elements. The Person element uses type DependentPersonData. This is a duplicate of the type PersonData used in Subscriber except the IdentificationCode is optional for a dependent.
|
Elements and Attributes [Global types listed alphabetically in following table.] |
ContentModel* |
Definition |
|
|
[ DependentDataType ] |
relationshipCode xsd:restriction base: xsd:string |
An element of Subscriber that captures all information related to the Dependent. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
xsd:restriction base: xsd:string [Enumerations]: Adopted Child, Brother or Sister, Brother-in-Law or Sister-in-Law, Child, Collateral Dependent, Court Appointed Guardian, Cousin, Dependent of a Minor Dependent, Ex-Spouse, Father, Father or Mother, Father-in-Law or Mother-in-Law, Foster Child, Grandfather or Grandmother, Grandson or Granddaughter, Guardian, Life Partner, Mother, Nephew or Niece, Self, Son-in-Law or Daughter-in-Law, Sponsored Dependent, Spouse, Stepfather, Stepmother, Stepson or Stepdaughter, Uncle or Aunt, Ward |
Indicates
the relationship between subscriber and dependent. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- xsd:boolean - |
Indicates if a student is attending full time. True/False. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- DependentPersonData - S (1/1) |
Contains various data about a person. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- CoverageType - S (1/1) |
Identifies
the type of coverage. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- MedicareData - S (0/1) |
Container for subscriber's Medicare information. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- MedicaidData - S (0/1) |
Container for subscriber's Medicaid information. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- HIPAAData - S (0/1) |
Health Information Portability and Accountability Act. Container for HIPAA related elements. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- CoordinationOfBenefitsInfoType - S (0/1) |
Contains information about other insurance coverage with which an insurer must coordinate payment. Contains an indicator of whether coordination of benefits is applicable and optionally the name of the other insurer and effective dating. See CoordinationOfBenefitsInfoType. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- SchoolData - S (0/*) |
Information about an educational institution. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
- CustodyInfoType - S (0/1) |
An optional field indicateing the type of legal custody for a child dependent. Enumerated values are: "both parents", "former spouse", "subscriber only", and "other or unknown". |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ School/ |
- xsd:string - S (1/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ School/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ School/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes inactive or ends.
|
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ School/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ |
PersonName
- PersonNameType - S
(1/1) |
Individual other than the parent responsible for the person. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ ResponsiblePerson/ |
- PersonNameType - S (1/1) |
The name of a person. |
|
|
/ Enrollment/
Organization/ Subscriber/ Dependent/ ResponsiblePerson/ |
- ContactMethodType - S (1/*) |
Contains
contact information. |
|
|
/ Enrollment/
Organization/ Subscriber/ Dependent/ |
PersonName
- PersonNameType - S
(1/1) |
Custodial parent of a minor dependent usually required when someone other than subscriber. |
|
|
/ Enrollment/
Organization/ Subscriber/ Dependent/ CustodialParent/ |
- PersonNameType - S (1/1) |
The name of a person. |
|
|
/
Enrollment/ Organization/ Subscriber/ Dependent/ CustodialParent/ |
- ContactMethodType - S (1/*) |
Contains
contact information. |
|
|
|
|
|
|
3.6.3 The Coverage Global Type
|
/ |
TierCoverage
- USTierCoverage - S
(0/*) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[Coverage]/ |
- USTierCoverage - S (0/*) |
Container for information about TierCoverages in which the person is enrolled. |
|
/
[Coverage]/ |
- USSpendingAccountCoverage - S (0/*) |
Contains information about Spending Accounts in which the individual is participating. |
|
/
[Coverage]/ |
- USRateBasedCoverage - S (0/*) |
Container for information about Rated Based Coverage in which the person is enrolled. |
3.6.4 The USTierCoverage Global Type
|
/ |
type -
USTierCoveragePlanType - required |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[USTierCoverage] / |
xsd:restriction base: xsd:string [Enumerations]: 24 Care, Dental, Dental Capitation, Exclusive Provider Organization, Health, Health Maintenance Organization, Hearing, Long Term Care, Long Term Disability, Mail Order Drug, Major Medical, Medicare Risk, Mental Health, Point of Service, Preferred Provider Organization, Prescription Drug, Preventative Care, Short Term Disability, Utilization Review, Vision |
Further defines the associated element in the context
provided. |
|
/
[USTierCoverage]/ |
xsd:restriction base: xsd:string [Enumerations]: Add, Audit, Change, Correction, Delete, Employee Information Not Available, Reinstatement, Termination |
A code
that applies to the individual records within a batch. |
|
/
[USTierCoverage]/ |
- xsd:string - S (0/1) |
Identifies the actual plan or option in which the person is enrolling. |
|
/
[USTierCoverage]/ |
- xsd:string - S (0/1) |
Group number for the plan in which the subscriber or dependent is enrolled. Group numbers may be constructed of a number of component parts. In such cases it recommended, but not required, that the components be separated with a colon - : |
|
/
[USTierCoverage]/ |
xsd:restriction base: xsd:string [Enumerations]: COBRA, non-COBRA |
Indicates whether a person is COBRA or non-COBRA. |
|
/
[USTierCoverage]/ |
- LocalDateType - S (1/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
[USTierCoverage]/ |
COBRAStartDate
- LocalDateType - S
(0/1) |
Contains information on the period of COBRA coverage and on the type and date of the qualifying event triggering COBRA eligibility. |
|
/
[USTierCoverage]/ COBRAInformation/ |
- LocalDateType - S (0/1) |
The date COBRA coverage begins. |
|
/ [USTierCoverage]/
COBRAInformation/ |
- LocalDateType - S (0/1) |
The date COBRA coverage ends. |
|
/
[USTierCoverage]/ COBRAInformation/ |
- LocalDateType - S (0/1) |
The date
through which this person's COBRA coverage is paid. |
|
/
[USTierCoverage]/ COBRAInformation/ |
- LocalDateType - S (0/1) |
The reported date associated with the qualifying event. |
|
/
[USTierCoverage]/ COBRAInformation/ |
xsd:restriction base: xsd:string [Enumerations]: Bankruptcy of a Retired Employee, Death, Divorce, Ineligible Child, Medicare, Reduction of work hours, Separation, Termination of Employment |
Indicates the event qualifying the person for COBRA continuation of coverage. |
|
/
[USTierCoverage]/ COBRAInformation/ |
- xsd:string - S (0/1) |
Contains
additional (non-regulatory) COBRA qualifying event data, as defined by the
trading partner agreement. |
|
/
[USTierCoverage]/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes inactive or ends.
|
|
/
[USTierCoverage]/ |
CoverageLevelCode
- [complexType] - S
(1/1) |
Container for all coverage information within USTierCoverage and USRateBasedCoverage. |
|
/
[USTierCoverage]/ CoverageLevel/ |
- [Union]: CoverageLevelCodeType, xStringPatternExtensionType |
Indicates
coverage level. |
|
/
[USTierCoverage]/ CoverageLevel/ |
- LocalDateType - S (1/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
[USTierCoverage]/ |
providerType
xsd:restriction
base: xsd:string [Enumerations]:
Obstetrics and Gynecology Facility, Doctor of Optometry, Primary Care
Provider, Pharmacy, Dentist, Managed Care Organization |
Information
about the provider associated with the coverage. |
|
/
[USTierCoverage]/ Provider/ |
xsd:restriction base: xsd:string [Enumerations]: Obstetrics and Gynecology Facility, Doctor of Optometry, Primary Care Provider, Pharmacy, Dentist, Managed Care Organization |
Indicates
the type of provider. |
|
/
[USTierCoverage]/ Provider/ |
xsd:restriction base: xsd:string [Enumerations]: Person, Non Person Entity |
Indicates
the type of provider. |
|
/
[USTierCoverage]/ Provider/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
[USTierCoverage]/ Provider/ |
- xsd:string - C (0/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
[USTierCoverage]/ Provider/ |
- PersonNameType - C (0/1) |
The name of a person. |
|
/
[USTierCoverage]/ Provider/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
|
/
[USTierCoverage]/ Provider/ |
xsd:extension base: xsd:string |
A unique identifier for the provider. |
|
/
[USTierCoverage]/ Provider/ ProviderId/ |
xsd:restriction base: xsd:string [Enumerations]: Social Security Number, Federal Taxpayer Identification Number, HCFA National Provider Identifier, Mutually Defined |
Indicates
the type of provider identification number. |
|
/
[USTierCoverage]/ Provider/ |
xsd:restriction base: xsd:string [Enumerations]: Established Patient, Not Established Patient, Not Known |
Indicates
the type of relationship the person has with the provider. |
|
/
[USTierCoverage]/ Provider/ |
xsd:restriction base: xsd:string [Enumerations]: Appointment Times Not Met in a Timely Manner, Current Customer Information File in Error, Dissatisfaction with Medical Care/Services Rendered, Dissatisfaction with Office Staff, Dissatisfaction with Physician's Referral Policy, Dissatisfied with Office Hours, Inconvenient Office Location, Less Respect/Attention/Time Given Than to Other Patients, No Reason Given, Patient Moved to a New Location, Plan Change, Unable to Scheduled Appointments in a Timely Manner, Voluntary Withdrawal, Dissatisfaction with Medical Care or Services Rendered, Dissatisfaction with Physician Referral Policy, Less Respect ir Attention or Time Given Than to Other Patients |
Reason why person is changing providers.
The following enumerations were deprecated because the special characters could cause errors with code generators.
Deprecated: Dissatisfaction with Medical Care/Services Rendered. Replaced by: Dissatisfaction with Medical Care or Services Rendered
Deprecated: Dissatisfaction with Physician's Referral Policy Replace by: Dissatisfaction with Physician Referral Policy
Deprecated: Less Respect/Attention/Time Given Than to Other Patients Replaced by: Less Respect or Attention or Time Given Than to Other Patients
|
|
/
[USTierCoverage]/ |
- LocalDateType - S (0/1) |
A date indicating the last day in which participation in the plan is possible. The context of the date may be broader than the individual (organization or group level) but is provided here at the individual level. |
|
/
[USTierCoverage]/ |
- LocalDateType - S (0/1) |
Indicates the date on file for the enrollment signature. |
|
/
[USTierCoverage]/ |
- CarrierData - S (0/1) |
Contains
information about the insurance carrier or other provider of benefits
coverage. |
|
/
[USTierCoverage]/ Carrier/ |
- xsd:string - S (0/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
[USTierCoverage]/ Carrier/ |
- EntityIdType - S (0/*) |
A unique
identifier used to reference the entity. The Id is associated with the higher
level element. |
|
/
[USTierCoverage]/ Carrier/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
|
/ [ USTierCoverage ]/ |
OrganizationName - xsd:string - S (0/1)
|
Contains identifying information related to the selection of a health care spending account (HSA) vendor. This element is used only if the tier coverage is elected in connection to a HSA offering. |
|
/ [ USTierCoverage ]/ |
- xsd:string - S (0/1) |
The name of the HSA vendor elected by the subscriber. Note that this usually would be used only if the elected vendor is other than the default HSA vendor. See UseDefaultAccountSponsor. |
|
/
[USSpendingAccountCoverage]/ HSAVendor/ |
- EntityIdType - S (0/*) |
A unique identifier used to reference the entity. The Id is associated with the higher level element. |
|
/
[USSpendingAccountCoverage]/ HSAVendor/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
|
/
[USSpendingAccountCoverage]/ HSAVendor/ |
- xsd:boolean - S (0/1) |
A Boolean that may be used to indicate whether the subscriber has elected the health plan’s default HSA vendor. |
|
/ [USSpendingAccountCoverage]/ HSAVendor/ SignatureDate |
- LocalDateType - S (0/1) |
Used to indicate that the subscriber’s signature selecting the indicated HSA vendor is on file with benefits administrator. Provides the signature date for that election. |
|
/
[USTierCoverage]/ |
- xsd:string - S (0/1) |
Postal
code used for eligibility determination. |
|
/
[USTierCoverage]/ |
- IdCardData - S (0/1) |
Container for capturing identification card insurance information. |
|
/
[USTierCoverage]/ IdCard/ |
- xsd:string - S (1/1) |
Describes the plan coverage. |
|
/
[USTierCoverage]/ IdCard/ |
- xsd:nonNegativeInteger - S (0/1) |
A
numerical quantity that is assigned or determined by calculation or
measurement. |
|
/
[USTierCoverage]/ IdCard/ |
xsd:restriction base: xsd:string [Enumerations]: Add, Change, Replace |
A code indicating the reason an ID card is requested for this benefit. |
|
/
[USTierCoverage]/ |
- xsd:string - S (0/1) |
The region which defines the location of the subscriber/dependent for purposes of plan eligibility in this coverage. |
|
/
[USTierCoverage]/ |
- LocalDateType - S (0/1) |
The date
an event was originally became effective. |
|
/ [USTierCoverage]/ |
- xsd:boolean - S (0/1) |
A boolean value indicating whether the person is enrolling outside the normal enrollment period. |
|
/ |
xsd:restriction base: xsd:string [Enumerations]: Children Only, Dependents Only, Employee and Children, Employee and Five or More Dependents, Employee and Four or More Dependents, Employee and One Dependent, Employee and One or More Dependents, Employee and Spouse, Employee and Three Dependents, Employee and Three or More Dependents, Employee and Two Dependents, Employee and Two or More Dependents, Employee Only, Family, Individual, Not Applicable, Spouse and Children, Spouse Only, Two Party, Employee and Domestic Partner, Domestic Partner and Children, Domestic Partner Only, Employee and Spouse or Domestic Partner, Child or Children of a Domestic Partner |
Globally scoped data type. See element or attribute declaration for definition. |
3.6.5 The USSpendingAccountCoverage Global Type
|
/ |
type xsd:restriction base:
xsd:string [Enumerations]: FSA Health
Care, FSA Dependent Care |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[USSpendingAccountCoverage] / |
xsd:restriction base: xsd:string [Enumerations]: FSA Health Care, FSA Dependent Care, Health Reimbursement Account |
Further defines the associated element in the context
provided. |
|
/
[USSpendingAccountCoverage]/ |
- xsd:string - S (0/1) |
Group number of the plan in which the subscriber or dependent is enrolled. |
|
/
[USSpendingAccountCoverage]/ |
xsd:restriction base: xsd:string [Enumerations]: Add, Audit, Change, Correction, Delete, Employee Information Not Available, Reinstatement, Termination |
A code
that applies to the individual records within a batch. |
|
/
[USSpendingAccountCoverage]/ |
- DateNkNaType - S (0/1) |
A date indicating the last day in which participation in the plan is possible. The context of the date may be broader than the individual (organization or group level) but is provided here at the individual level. |
|
/
[USSpendingAccountCoverage]/ |
- xsd:gYear - S (1/1) |
Indicates the year for which this plan applies. |
|
/
[USSpendingAccountCoverage]/ |
- LocalDateType - S (0/1) |
The start date for the current plan year. Used with PlanEndDate when a finer-grain option to PlanYear is required (e.g., a partial year). |
|
/ [USSpendingAccountCoverage]/ |
- LocalDateType - S (0/1) |
The end date for the current plan year. Used with PlanStartDate when a finer-grain option to PlanYear is required (e.g., a partial year). |
|
/
[USSpendingAccountCoverage]/ |
- LocalDateType - S (1/1) |
Start date for the Spending Account Coverage. Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
[USSpendingAccountCoverage]/ |
- LocalDateType - S (0/1) |
End date
for the Spending Account Coverage. Contains the (inclusive) date, period, or
interval the event becomes inactive or ends. |
|
/
[USSpendingAccountCoverage]/ |
contributor
xsd:restriction
base: xsd:string [Enumerations]:
Employer, Employee |
Container for Spending Account contribution information. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ |
xsd:restriction base: xsd:string [Enumerations]: Employer, Employee |
Indicates whether the contributor is the Employer or the Employee. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ |
xsd:extension base: xsd:double |
Indicates the annual goal amount. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ GoalAmount/ |
- CurrencyCodeType - |
A
three-letter code identifying the currency of a monetary amount. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ |
xsd:extension base: xsd:double |
Indicates the amount per pay period. |
|
/ [USSpendingAccountCoverage]/
ContributionData/ PerPayPeriodAmount/ |
- CurrencyCodeType - |
A
three-letter code identifying the currency of a monetary amount. |
|
/ [USSpendingAccountCoverage]/
ContributionData/ |
xsd:extension base: xsd:double |
Indicates the year-to-date contribution amount. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ YTDContributionAmount/ |
- CurrencyCodeType - |
A
three-letter code identifying the currency of a monetary amount. |
|
/
[USSpendingAccountCoverage]/ ContributionData/ |
xsd:restriction base: xsd:string [Enumerations]: Annually, Bi-Weekly, Daily, Monthly, One Time Only, Quarterly, Semi-Annually, Semi-Monthly, Weekly |
Indicates
the frequency of the contribution. |
|
/
[USSpendingAccountCoverage]/ |
xsd:extension base: xsd:double |
Indicates the rollover balance, if any, from the previous year. |
|
/
[USSpendingAccountCoverage]/ RolloverBalance/ |
- CurrencyCodeType - |
A
three-letter code identifying the currency of a monetary amount. |
|
/
[USSpendingAccountCoverage]/ |
- CarrierData - S (0/1) |
Contains
information about the insurance carrier or other provider of benefits
coverage. |
|
/
[USSpendingAccountCoverage]/ Carrier/ |
- xsd:string - S (0/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
[USSpendingAccountCoverage]/ Carrier/ |
- EntityIdType - S (0/*) |
A unique identifier used to reference the entity. The Id is associated with the higher level element. |
|
/
[USSpendingAccountCoverage]/ Carrier/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
|
/
[USSpendingAccountCoverage]/ |
AccountType
- xsd:string - S
(1/1) |
Container for all direct deposit information. |
|
/
[USSpendingAccountCoverage]/ DirectDepositData/ |
xsd:restriction base: xsd:string [Enumerations]: Checking, Savings |
Indicates type of account. |
|
/
[USSpendingAccountCoverage]/ DirectDepositData/ |
- xsd:string - S (1/1) |
Indicates ABA bank routing number. |
|
/
[USSpendingAccountCoverage]/ DirectDepositData/ |
- xsd:string - S (1/1) |
Indicates a bank account number. |
|
/
[USSpendingAccountCoverage]/ |
- AutoReimbursementType - S (0/1) |
An indicator of how auto reimbursement of claims should be administered. Enumerated values are “all”; “none”; and “byClaim”. |
3.6.6 The USRateBasedCoverage Global Type
|
/ |
TransactionCode - EnrollmentTransactionType - S (0/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/ [USRateBasedCoverage]/ |
- EnrollmentTransactionType - S (0/1) |
A code that applies to the
individual records within a batch. |
|
/ [USRateBasedCoverage]/ |
- xsd:string - S (0/1) |
Identifies the actual plan or option in which the person is enrolling. |
|
/ [USRateBasedCoverage]/ |
- xsd:string - S (0/1) |
Group number for the plan in which the subscriber or dependent is enrolled. |
|
/ [USRateBasedCoverage]/ |
Product - [complexType] - S (1/1) |
Indicates the type of coverage. |
|
/ [USRateBasedCoverage]/
CoverageType/ |
- [Union]: ProductType, xStringPatternExtensionType |
Describes the product. [Example(s): Life Insurance, Accidental Death and Dismemberment Insurance, Long Term Disability ] |
|
/ [USRateBasedCoverage]/ CoverageType/ |
- [Union]: ProductTypeType, xStringPatternExtensionType |
Indicates the product type. |
|
/ [USRateBasedCoverage]/
CoverageType/ |
xsd:restriction base: xsd:string [Enumerations]: Self, Spouse, Common Law Spouse, Dependent, Child |
Indicates who is covered. |
|
/ [USRateBasedCoverage]/ |
- CarrierData - S (0/1) |
Contains information about the
insurance carrier or other provider of benefits coverage. |
|
/ [USRateBasedCoverage]/ Carrier/ |
- xsd:string - S (0/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/ [USRateBasedCoverage]/ Carrier/ |
- EntityIdType - S (0/*) |
A unique identifier used to
reference the entity. The Id is associated with the higher level element. |
|
/ [USRateBasedCoverage]/ Carrier/ |
- ContactMethodType - S (0/*) |
Contains contact information. |
|
/ [USRateBasedCoverage]/ |
- LocalDateType - S (1/1) |
Contains the (inclusive) date, period,
or interval the event becomes active or begins. |
|
/ [USRateBasedCoverage]/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date,
period, or interval the event becomes inactive or ends. |
|
/ [USRateBasedCoverage]/ |
ApprovedCoverage - xsd:double - S (0/1) |
Container for all coverage information within USTierCoverage and USRateBasedCoverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ |
Level - xsd:double
- S (0/1) |
Container for information about
the approved benefits coverage. ] |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ |
CoverageLevelValue - xsd:double - S (1/1) |
Container for the level of coverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ Level/ |
xsd:extension base: xsd:double |
Indicates the monetary value of the coverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ Level/ CoverageLevelValue/ |
- CurrencyCodeType - |
A three-letter code identifying
the currency of a monetary amount. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ Level/ |
- xsd:double - S (1/1) |
Indicates the multiplier of the
coverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ Level/ |
xsd:restriction base: xsd:string [Enumerations]: Salary, YearsOfService, Fixed |
Indicates the type of coverage
level. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ |
xsd:extension base: xsd:double |
Indicates the total volume of the
benefit. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ ApprovedCoverage/ Volume/ |
- CurrencyCodeType - |
A three-letter code identifying
the currency of a monetary amount. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ |
Level - xsd:double
- S (0/1) |
Container for the requested coverage. |
|
/ [USRateBasedCoverage]/ CoverageLevel/
RequestedCoverage/ |
CoverageLevelValue - xsd:double - S (1/1) |
Container for the level of coverage. |
|
/ [USRateBasedCoverage]/ CoverageLevel/
RequestedCoverage/ Level/ |
xsd:extension base: xsd:double |
Indicates the monetary value of the coverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ RequestedCoverage/ Level/ CoverageLevelValue/ |
- CurrencyCodeType - |
A three-letter code identifying
the currency of a monetary amount. |
|
/ [USRateBasedCoverage]/ CoverageLevel/
RequestedCoverage/ Level/ |
- xsd:double - S (1/1) |
Indicates the multiplier of the
coverage. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ RequestedCoverage/ Level/ |
xsd:restriction base: xsd:string [Enumerations]: Salary, YearsOfService, Fixed |
Indicates the type of coverage
level. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ RequestedCoverage/ |
xsd:extension base: xsd:double |
Indicates the total volume of the
benefit. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ RequestedCoverage/ Volume/ |
- CurrencyCodeType - |
A three-letter code identifying
the currency of a monetary amount. |
|
/ [USRateBasedCoverage]/
CoverageLevel/ |
- LocalDateNaType - S (1/1) |
Contains the (inclusive) date,
period, or interval the event becomes active or begins. |
|
/ [USRateBasedCoverage]/ |
questionID - xsd:int
- required |
A textual query designed to
generate an answer or response. |
|
/ [USRateBasedCoverage]/
Question/ |
- xsd:int - |
Unique identifier for the question. |
|
/ [USRateBasedCoverage]/
Question/ |
- xsd:string - S (0/1) |
Text for a question. |
|
/ [USRateBasedCoverage]/
Question/ |
- xsd:string - S (1/1) |
Textual response to a particular
question. |
|
/ [USRateBasedCoverage]/ |
- xsd:boolean - S (0/1) |
A boolean value indicating whether the employer has Evidence of Insurability on File. |
|
/ [USRateBasedCoverage]/ |
- xsd:boolean - S (0/1) |
A boolean value indicating whether the Evidence of Insurability (EOI) is required by the employer. |
|
/ [USRateBasedCoverage]/ |
PersonName - PersonNameType - C (1/1) |
High level container to describe the plan beneficiary. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- PersonNameType - C (1/1) |
The name of a person. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- xsd:string - C (1/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- ContactMethodType - S (0/*) |
Contains contact information. [Example(s): Fax, E-mail, Telephone, Mobile Phone, Pager ] |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- DateNkNaType - S (0/1) |
A person's birth date. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
xsd:restriction base: xsd:string [Enumerations]: Adopted Child, Brother or Sister, Brother-in-Law or Sister-in-Law, Child, Collateral Dependent, Court Appointed Guardian, Cousin, Dependent of a Minor Dependent, Ex-Spouse, Father, Father or Mother, Father-in-Law or Mother-in-Law, Foster Child, Grandfather or Grandmother, Grandson or Granddaughter, Guardian, Life Partner, Mother, Nephew or Niece, Self, Son-in-Law or Daughter-in-Law, Sponsored Dependent, Spouse, Stepfather, Stepmother, Stepson or Stepdaughter, Uncle or Aunt, Ward |
Context definition: Indicates the beneficiary's relationship to insured. For example, Spouse, Father, Brother-in-Law. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- EntityIdType - S (0/1) |
A unique identifier used to
reference the entity. The Id is associated with the higher level element. |
|
/ [USRateBasedCoverage]/ BeneficiaryData/ |
xsd:extension base: xsd:double |
Amount of inheritance. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ InheritanceAmount/ |
xsd:restriction base: xsd:string [Enumerations]: Percentage, MonetaryAmount |
Indicates the type of amount. This might be a percentage or monetary amount. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- xsd:integer - S (0/1) |
Indicates the order in which the
beneficiary receives the payments |
|
/ [USRateBasedCoverage]/ BeneficiaryData/ |
- LocalDateNkNaType - S (1/1) |
Contains the (inclusive) date,
period, or interval the event becomes active or begins. |
|
/ [USRateBasedCoverage]/
BeneficiaryData/ |
- LocalDateNaType - S (0/1) |
Contains the (inclusive) date,
period, or interval the event becomes inactive or ends. |
|
/ [USRateBasedCoverage]/ |
- xsd:string - S (0/1) |
Postal code used for eligibility
determination. |
|
/ [USRateBasedCoverage]/ |
- xsd:boolean - S (0/1) |
A boolean value indicating whether the person is enrolling outside the normal enrollment period. |
|
/ |
xsd:restriction base: xsd:string [Enumerations]: Add, Audit, Change, Correction, Delete, Employee Information Not Available, Reinstatement, Termination |
Globally scoped data type. See element or attribute declaration for definition. |
|
/ |
xsd:restriction base: xsd:string [Enumerations]: Life Insurance, Accidental Death and Dismemberment Insurance, Long-Term Disability Insurance, Short-Term Disability Insurance |
Globally scoped data type. See element or attribute declaration for definition. |
|
/ |
xsd:restriction base: xsd:string [Enumerations]: Not Applicable, Supplemental, Basic, Group |
Globally scoped data type. See element or attribute declaration for definition. |
3.6.7 The EmploymentData Global Type
|
/ |
employeeId
- xsd:string - |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[EmploymentData] / |
- xsd:string - |
The identification code of the employee as defined by the employer. |
|
/
[EmploymentData]/ |
EmploymentStatusCode
- xsd:string - S
(1/1) |
Container for employment status information. |
|
/
[EmploymentData]/ EmploymentStatus/ |
xsd:restriction base: xsd:string [Enumerations]: Active Foreign Military, Active Domestic Military, Active, Leave of Absence, Short Term Disability, Long Term Disability, Retired, Terminated |
Indicates the status of the employee. |
|
/
[EmploymentData]/ EmploymentStatus/ |
- LocalDateType - S (1/1) |
Contains
the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/
[EmploymentData]/ |
EmploymentLevelCode
- xsd:string - S
(1/1) |
Container to indicate full-time or part-time employment. |
|
/
[EmploymentData]/ EmploymentLevel/ |
xsd:restriction base: xsd:string [Enumerations]: Full Time, Part Time |
Code indicating whether an employee is full-time or part-time. |
|
/ [EmploymentData]/
EmploymentLevel/ |
- LocalDateType - S (1/1) |
Contains the (inclusive) date, period, or interval the
event becomes active or begins. |
|
/
[EmploymentData]/ |
EmploymentOrganizationGroup
- xsd:string - S
(1/1) |
Contains the information regarding how the subscriber belongs to the employer. |
|
/
[EmploymentData]/ EmploymentOrganization/ |
- xsd:string - S (1/1) |
Indicates
the particular organization group. |
|
/
[EmploymentData]/ EmploymentOrganization/ |
- xsd:string - S (1/1) |
Indicates
the particular organization group type. |
|
/ [EmploymentData]/
EmploymentOrganization/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the
event becomes active or begins. |
|
/
[EmploymentData]/ |
- LocalDateType - S (0/1) |
Date the
person was originally hired by the organization. |
|
/
[EmploymentData]/ |
- LocalDateType - S (0/1) |
The date this person was first hired by the organization. |
|
/
[EmploymentData]/ |
- LocalDateType - S (0/1) |
Contains the actual employment termination date, if applicable. |
|
/ [EmploymentData]/ |
- LocalDateType - S (0/1) |
Indicates the last day the subscriber worked for the employer. |
|
/
[EmploymentData]/ |
- LocalDateType - S (0/1) |
The date
on which a subscriber is expected to return to work. |
|
/
[EmploymentData]/ |
xsd:restriction base: xsd:string [Enumerations]: American Indian or Alaskan Native, Asian or Pacific Islander, Black, Black (Non-Hispanic), Caucasian, Hispanic, Not Provided, White (Non-Hispanic) |
A code
used to identify the race of the person as defined by the Equal Employment
Opportunity Commission. |
|
/ [EmploymentData]/ |
- xsd:boolean - S (0/1) |
Indicates whether the employee is considered a VIP (Very Important Person) by the employer. |
3.6.8 The MedicareData Global Type
Note that the MedicareData GlobalType has been significantly revised. The pre-existing components have been maintained for backward compatibility, but have been deprecated. These deprecated components should be avoided in new implementations and will be removed in a future version of the schema.
|
/ |
- MedicareData - (1/1) |
Contains Medicare information for a subcriber or dependent. |
|
/ Medicare/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins.
|
|
/ Medicare/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. [Deprecated: Maintained for backward compatibility. Going forward implementers should use the effective dating available under the MedicarePartA, MedicarePartB, and MedicarePartD components. ] |
|
/ Medicare/ |
- xsd:string - S (0/1) |
Subscriber's Medicare Part A number.
[Deprecated: Maintained for backward compatibility. Going forward implementers should use HealthInsuranceClaimNumber. ] |
|
/ Medicare/ |
- xsd:string - S (0/1) |
Subscriber's Medicare Part B number.
[Deprecated: Maintained for backward compatibility. Going forward implementers should use HealthInsuranceClaimNumber. ] |
|
/ Medicare/ |
IsEligible - MedicareIsEligibleTypesType
- S (0/1) |
Contains information indicating whether the individual is entitled to the U.S. Medicare program and relevant effective dating. |
|
/ Medicare/ MedicareEntitlement/ |
- MedicareIsEligibleTypesType - S (0/1) |
Indicates whether the individual is eligible for the program. |
|
/ Medicare/ MedicareEntitlement/ |
- EntitlementReasonCodeTypesType - S (0/1) |
A reason making a person eligible under the U.S. Medicare program. Enumerated values are: age; ESRD (end-stage renal disease); disabled; working disabled; unknown. |
|
/ Medicare/ MedicareEntitlement/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins. |
|
/ Medicare/ MedicareEntitlement/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. |
|
/ Medicare/ |
- xsd:string - S (0/1) |
A "Health Insurance Claim Number," sometimes referred to as a "HIC No," is the primary Medicare reference number. It is used when filing claims. [Note: Replaces MedicarePartANumber and MedicarePartBNumber,
which are deprecated.] |
3.6.8.1 MedicarePartA
|
/ Medicare/ |
- MedicareCoverageBaseType - S (0/1) |
This element contains information about the individual's Medicare Part A eligibility and enrollment. Medicare Part A is the Hospital Insurance portion of the U.S. Medicare program. |
|
/ Medicare/ MedicarePartA/ |
- MedicareIsEnrolledTypesType - S (0/1) |
Indicates whether the individual is enrolled in the particular plan. Enumerated values are "yes," "no," "unknown," and "not applicable". |
|
/ Medicare/ MedicarePartA/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins. |
|
/ Medicare/ MedicarePartA/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. |
3.6.8.2 MedicarePartB
|
/ Medicare/ |
- MedicareCoverageBaseType - S (0/1) |
This element contains information about the individual's Medicare Part B eligibility and enrollment. Medicare Part B is the portion of the U.S. Medicare program covering physician services. |
|
/ Medicare/ MedicarePartB/ |
- MedicareIsEnrolledTypesType - S (0/1) |
Indicates whether the individuals is enrolled in the particular plan. Enumerated values are "yes," "no," "unknown," and "not applicable". |
|
/ Medicare/ MedicarePartB/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins. |
|
/ Medicare/ MedicarePartB/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. |
3.6.8.3 MedicarePartD
|
/ Medicare/ |
- MedicareCoveragePartDType - S (0/1) |
This element contains information about the individual's Medicare Part D program eligibility and enrollment as well as details about the specific drug plan in which the individual is enrolled. |
|
/ Medicare/ MedicarePartD/ |
- MedicareDrugPlanInfoType - S (0/1) |
Contains information about an individual's drug plan enrollment. |
|
/ Medicare/ MedicarePartD/ MedicareDrugPlanInfo/ |
- EntityIdType - S (0/1) |
Identifies a benefit option available under the particular drug plan. A plan-defined value. |
|
/ Medicare/ MedicarePartD/ MedicareDrugPlanInfo/ |
DrugPlanCoverageType - MedicareDrugPlanTypesType
- S (1/1) |
Contains information about the individual's Medicare Part D drug plan coverage. Indicates the type of Part D coverage and relevant effective dating. |
|
/ Medicare/ MedicarePartD/ MedicareDrugPlanInfo/
DrugPlanCoverage/ |
- MedicareDrugPlanTypesType - S (1/1) |
Identifies the type of Medicare Part D coverage. Enumerated values are: Part D Subsidy Program; Integrated Wrapped Secondary Coverage; Not Participating Subsidy; Not Participating; and Unknown. |
|
/ Medicare/ MedicarePartD/ MedicareDrugPlanInfo/
DrugPlanCoverage/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes active or begins. |
|
/ Medicare/ MedicarePartD/ MedicareDrugPlanInfo/
DrugPlanCoverage/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event becomes inactive or ends. |
3.6.9 The MedicaidData Global Type
|
/ |
StartDate
- LocalDateType - S
(1/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[MedicaidData]/ |
- LocalDateType - S (1/1) |
Contains the (inclusive) date, period, or interval the
event becomes active or begins. |
|
/
[MedicaidData]/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes inactive or ends.
|
3.6.10 The HIPAAData Global Type
|
/ |
PriorCoverageMonths - xsd:nonNegativeInteger - S (1/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[HIPAAData]/ |
- xsd:nonNegativeInteger - S (1/1) |
Reports the number of prior months during which this person had medical coverage. The derivation of this value is related to HIPAA legislation regarding the portability of health insurance. |
3.6.11 The PersonData Global Type
This structure is identical to the DependentPersonData type, with the exception of the Identification Code, which is required in the PersonData type and optional in the DependentPersonData type. For expediency, only the PersonData type is described.
|
/ |
IdentificationCode - EntityIdType - S (1/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/ [PersonData]/ |
- EntityIdType - S (1/1) |
A unique identifier used to
reference the entity. The Id is associated with the higher level element. |
|
/ [PersonData]/ |
- EntityIdType - S (0/1) |
Used to report an identification
code previously reported to the downstream partner later corrected by a
subsequent transaction. |
|
/ [PersonData]/ |
- PersonNameType - S (1/1) |
The name of a person. |
|
/ [PersonData]/ |
- PersonNameType - S (0/1) |
Used to report a person name
previously reported to the downstream partner later corrected by a subsequent
transaction. |
|
/ [PersonData]/ |
- GenderCodeType - S (1/1) |
Signifies to the system the
gender of the person. |
|
/ [PersonData]/ |
- GenderCodeType - S (0/1) |
Used to report a gender
previously reported to the downstream partner later corrected by a subsequent
transaction. |
|
/ [PersonData]/ |
- LocalDateType - S (1/1) |
A person's birth date. |
|
/ [PersonData]/ |
- LocalDateType - S (0/1) |
Used to report a date of birth
previously reported to the downstream partner later corrected by a subsequent
transaction. |
|
/ [PersonData]/ |
- LocalDateType - S (0/1) |
Date of death for subscriber or
dependent. |
|
/ [PersonData]/ |
- ContactMethodType - S (0/*) |
Contains contact information. |
|
/ [PersonData]/ |
- LanguageData - S (0/*) |
Contains information about a single
language. |
|
/ [PersonData]/ Language/ |
xsd:restriction base: xsd:string |
Code indicating a language. |
|
/ [PersonData]/ Language/ |
xsd:restriction base: xsd:string [Enumerations]: Written, Spoken |
Indicates how a language is used
or expressed. |
|
/ [PersonData]/ |
xsd:extension base: xsd:double |
Specifies the height of a person. |
|
/ [PersonData]/ Height/ |
xsd:restriction base: xsd:string [Enumerations]: inches, centimeters |
Describes the quantity in which
the item is measured. |
|
/ [PersonData]/ |
xsd:extension base: xsd:double |
A number to indicate the physical
weight of the person. |
|
/ [PersonData]/ Weight/ |
xsd:restriction base: xsd:string [Enumerations]: pounds, kilograms |
Describes the quantity in which
the item is measured. |
|
/ [PersonData]/ |
- xsd:boolean - S (0/1) |
Code indicating whether this person is a substance abuser. Included for 834 compatibility. |
|
/ [PersonData]/ |
- xsd:boolean - S (0/1) |
Indicates whether or not this person is a tobacco user. |
|
/ [PersonData]/ |
MaritalStatusCode - xsd:string - S (1/1) |
Contains information on the marital status of the person. |
|
/ [PersonData]/ MaritalStatus/ |
xsd:restriction base: xsd:string [Enumerations]: Divorced, Legally Separated, Married, Registered Domestic Partner, Separated, Single, Unmarried, Unreported, Widowed |
Code indicating person's marital status. |
|
/ [PersonData]/ MaritalStatus/ |
- LocalDateNkNaType - S (1/1) |
Contains the (inclusive) date,
period, or interval the event becomes active or begins. |
|
/ [PersonData]/ |
DisabilityType - xsd:string - S (1/1) |
Relevant information about the person's disabilities. |
|
/ [PersonData]/ Disability/ |
xsd:restriction base: xsd:string [Enumerations]: Short Term Disability, Long Term Disability, Permanent or Total Disability, No Disability |
Contains the type of disability. For example, short term disability or permanent. |
|
/ [PersonData]/ Disability/ |
- LocalDateNkNaType - S (1/1) |
Contains the (inclusive) date,
period, or interval the event becomes active or begins. |
|
/ [PersonData]/ |
OrganizationName - xsd:string - C (1/1) |
Container for employer-related information. |
|
/ [PersonData]/ Employer/ |
- xsd:string - C (1/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/ [PersonData]/ Employer/ |
- PersonNameType - C (1/1) |
The name of a person. |
|
/ [PersonData]/ Employer/ |
- ContactMethodType - S (0/*) |
Contains contact information. |
|
/ [PersonData]/ Employer/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date,
period, or interval the event becomes active or begins. |
|
/ [PersonData]/ |
- xsd:boolean - S (0/1) |
Indicates whether or not this person is considered a student. |
|
/ [PersonData]/ |
- xsd:boolean - S (0/1) |
Indicates whether or not this person is considered to be disabled. |
3.6.12 The LanguageData Global Type
|
/ |
languageCodeQualifier - xsd:string - |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[LanguageData] / |
- xsd:string - |
Defines
the language code used by the LanguageData element. |
|
/
[LanguageData] / |
xsd:restriction base: xsd:string [Enumerations]: Native Language, Reading Language, Speaking Language |
Describes
the purpose of language use. |
|
/
[LanguageData]/ |
xsd:restriction base: xsd:string |
Code
indicating a language. |
|
/
[LanguageData]/ |
xsd:restriction base: xsd:string [Enumerations]: Written, Spoken |
Indicates
how a language is used or expressed. |
3.6.13 The CarrierData Global Type
|
/ |
OrganizationName
- xsd:string - S
(0/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[CarrierData]/ |
- xsd:string - S (0/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
[CarrierData]/ |
- EntityIdType - S (0/*) |
A unique identifier used to reference the entity. The Id is associated with the higher level element. |
|
/
[CarrierData]/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
3.6.14 The IdCardData Global Type
|
/ |
idCardType
xsd:restriction
base: xsd:string [Enumerations]: Dental
Insurance, Health Insurance, Prescription Drug Service Insurance |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[IdCardData] / |
xsd:restriction base: xsd:string [Enumerations]: Dental Insurance, Health Insurance, Prescription Drug Service Insurance |
Describes
the type of insurance card. |
|
/
[IdCardData]/ |
- xsd:string - S (1/1) |
Describes the plan coverage. |
|
/
[IdCardData]/ |
- xsd:nonNegativeInteger - S (0/1) |
A
numerical quantity that is assigned or determined by calculation or
measurement. |
|
/
[IdCardData]/ |
xsd:restriction base: xsd:string [Enumerations]: Add, Change, Replace |
A code indicating the reason an ID card is requested for this benefit. |
3.6.15 The SchoolData Global Type
|
/ |
OrganizationName
- xsd:string - S
(1/1) |
Globally scoped data type. See element or attribute declaration for definition. |
|
/
[SchoolData]/ |
- xsd:string - S (1/1) |
The name by which an organization or enterprise is known as established under the laws of a country, state, province or ruling governmental body for the purpose of conducting business transactions. |
|
/
[SchoolData]/ |
- LocalDateType - S (0/1) |
Contains the (inclusive) date, period, or interval the event
becomes active or begins. |
|
/
[SchoolData]/ |
- LocalDateType - S (0/1) |
Contains
the (inclusive) date, period, or interval the event becomes inactive or ends.
|
|
/
[SchoolData]/ |
- ContactMethodType - S (0/*) |
Contains
contact information. |
4 Implementation Considerations
4.1 Introduction
The successful adoption of any benefit enrollment standard requires consistent interpretation among trading partners of certain enrollment situations. This section provides practical guidelines for using the HR-XML Benefit Enrollment schema in these situations. While an attempt is made to recommend a preferred approach for interpreting these situations, it is recognized that the capabilities of current source and receiving systems may vary widely from the suggested approach. For many situations an alternative approach is provided.
4.2 Update versus Replacement File Reporting
In most cases, an XML document conforming to the Benefits Enrollment schema will be used to transmit new or updated enrollment data. The TransactionCode element (an optional child element of the Coverage complex type) indicates the nature of the transaction as it is interpreted by the sender. The possible values of TransactionCode are:
· Add
· Change
· Delete
· Termination
· Reinstatement
· Correction
· Audit
The Enrollment element has an optional TransactionType attribute (included in the schema primarily for compatibility with ANSI 834). This attribute has two possible values: “Change” or “Full.” TransactionType can be set to “Change” when the transmitted XML file includes only current period change activity and to “Full” when the data in the XML file is intended to replace the receiving system’s database with the current state of the sending system’s database. Because of the inefficiencies inherent in full-file processing, we do not recommend the use of Full files for regular maintenance. However, for Full files, it is recommended that a receiving system not assume terminations based on the absence of an enrolled member. If terminations due to absence are to be used, it must be stipulated in a trading partner agreement.
The Benefits Enrollment schema also supports periodic audits to compare data between sending and receiving systems. To accomplish this, a conforming XML document should include all available information about subscribers and dependents with coverage as of an agreed-upon effective date. The Enrollment element’s TransactionType can optionally be set to “Full” and a TransactionCode with a value of “Audit” should be used for every instance of the Coverage complex type.
4.3 Complete Family Reporting versus Individual Changes Only
For the purposes of Update File reporting, it is RECOMMENDED that complete family units be sent whenever there is a change to any member of the family. In other words, the unit of work for an update transaction is all members of the family regardless of who or what is actually changing.
4.4 Correcting Person Identifier, Name and Demographic Data
Changing or correcting person data requires special
attention to assure these changes are treated as “updates” and not
“adds” by the receiving system. The Benefit Enrollment schema will
always assume Person Identifier (typically Social Security Number in the
In the event that the source system does not store Prior Incorrect information, the receiving system must use the data provided to process the person changes. The receiver should determine, based on their own processing, whether or not they require Prior Incorrect information for updates to key person data.
4.5 Coverage Level for Dependents
It is RECOMMENDED that the CoverageLevelCode be the same for the subscriber and all dependents when the subscriber and dependent(s) have coverage. However, when a dependent is terminated from a family unit that remains covered, the CoverageLevel for the terminated dependent should be the last coverage level code of record and the start date should be the last date of coverage. If the prior CoverageLevelCode is not known by the sender, a value of "Not Applicable" should be sent.
See termination example in the Enrollment Reference Examples document (Appendix B – Related Documents).
4.6 COBRA Eligible; Not Enrolled
Source systems have the legal obligation to inform the health carrier that a terminated person may be eligible for COBRA – even before the person has elected COBRA. This is needed for health plans to accurately inform people of their COBRA status in a timely manner.
The Benefit Enrollment schema supports this requirement by providing a COBRA Qualifying Event Code and a COBRA Qualifying Event Date on coverage termination transactions. Source systems are RECOMMENDED to provide the COBRA Qualifying Event Code and COBRA Qualifying Event Date. Receiving systems are RECOMMENDED to use this information to terminate current coverage, while still accurately recognizing the person as COBRA eligible.
4.7 COBRA Enrolled; Premium Not Paid
Once a COBRA Eligible person has made a COBRA election, the source system is legally obligated to send the election to the health carrier system, regardless of whether or not the person has made their initial COBRA premium payment. The source system MUST support this requirement by sending an “add” enrollment transaction and including the following COBRA elements: COBRA Status of “COBRA”, COBRA Start Date equal to the date COBRA benefits commence, COBRA Qualifying Event Date and COBRA Qualifying Event Code. If the COBRA Enrolled person has yet to make a COBRA payment, the COBRA Paid Through Date element will not be available and therefore will not be sent. Receiving systems MUST interpret this as a bona fide election.
4.8 COBRA Enrolled; Premium Paid
COBRA enrollees with continuing coverage will be reported using all available COBRA information and including a current COBRA Paid Through Date. The COBRA Paid Through Date is interpreted as the date through which COBRA premiums have been paid and thus the date through which claims may be paid. The COBRA Paid Through Date MUST be updated by normal periodic maintenance. The receiving systems SHALL not terminate COBRA enrollments based on the COBRA Paid Through Date alone; instead the source system will explicitly terminate COBRA enrollees with delinquent premiums once all grace periods are exceeded.
4.9 Receiving System Derives Group or Policy Numbers
The Benefit Enrollment schema supports the possibility that the receiving system may derive group or policy numbers in whole or in part based on information provided by the source system. The derivation by the receiving system of these group or policy numbers is typically based on a combination of Employment, Organization, Coverage and/or some other client specific reporting requirements.
The Employment Status, Employment Organization, Benefit Reporting Information and Elected Plan Code elements may be used individually or in combination to support this requirement. Specific agreements between trading partners will govern the source, use and interpretation of these elements to meet this requirement.
If the sending system derives the group or policy number, this data SHOULD be sent in the GroupNumber element. A trading partner agreement will determine how this information is used by the receiving system.
4.10 Coverage Terminations
The RECOMMENDED approach for communicating explicit coverage terminations is to send the subscriber with a TransactionCode value of ‘Termination’ and a TierCoverage EndDate populated with the subscriber’s and/or dependent’s last date of coverage.
4.11 Split Family Enrollment
1) If a subscriber and dependent(s) are enrolled with coverage in the same
carrier, but with different GroupNumbers (ie: pre/post 65), all covered family
members should be reported within the same HR-XML transaction. The Benefit
Enrollment schema supports this situation by reporting each family member with
their respective GroupNumber value and a CoverageLevelCode reflecting all
covered family members, regardless of GroupNumber variations.
2) If a subscriber and dependents are enrolled with coverage in different
carriers, or the subscriber elects dependent only coverage, the dependent
coverage should be reported in a HR-XML transaction separate from the subscriber.
The Benefit Enrollment schema supports this situation by reporting the
dependent as a subscriber, with a "Dependent-only Coverage"
SubscriberTypeCode and with the OriginatingSubscriberId set to the original
subscriber's SSN (or the original subscriber's IdentificationCode value). The
receiving system should enroll the covered dependent in manner that will
maintain the claim history.
Any variations to the above process should be specified in a trading partner
agreement.
4.12 Originating SSN for Surviving Dependents
Surviving dependent enrollments occur when the plan rules of the sponsor provide continued coverage for dependents in the event of the death of the originating subscriber. The Benefit Enrollment schema supports this situation by reporting the surviving dependent as a subscriber, with a "Survivorship" SubscriberTypeCode and with the OriginatingSubscriberId set to the deceased subscriber's SSN (or the original subscriber's IdentificationCode value). The receiving system will enroll the surviving dependent(s) in a manner that will maintain the claim history. Any variations to the above process should be specified in a trading partner agreement.
4.13 Spending Account Enrollments
Enrollment information for a flexible spending account (FSA) contains a variety of attributes. The schema accommodates up to four elements (GoalAmount, PerPayPeriodAmount, YTDContributionAmount, and Frequency) to capture FSA enrollment attributes. However, only the GoalAmount and two of the other three are REQUIRED to calculate the enrollment. For example, if an employee elects a $1200 GoalAmount, a $100 PerPayPeriodAmount, and a Frequency equal to “Monthly”, then one can assume that the YTDContributionAmount is zero. In another example, if the GoalAmount is $260, the Frequency is “Weekly”, and the YTDContributionAmount is $130, then one can assume that the PerPayPeriodAmount is $5.
4.14 Healthcare Spending Accounts (HSAs)
A Healthcare Spending Account (HSA) is a tax-exempt account established exclusively for the purpose of paying qualified medical expenses of account beneficiaries. One condition for establishing HSA, is for the HSA beneficiary to be covered under a high-deductible health plan. Because an HSA is always paired with a high-deductible plan and because the HSA itself is typically maintained by a separate financial services company (referred to in this specification as the “HSA vendor”), the HSA-related information communicated within an enrollment between a benefits administrator and a health plan can be relatively thin.
The Tier Coverage component of HR-XML’s Enrollment schema is designed to communicate health and other tier-coverage enrollments from a benefit administer to a health plan. In the case of an HSA program, the high-deductible health plan enrollment is accomplished using the Tier Coverage component. In some cases, the HSA vendor could be a “preferred” or “default” HSA vendor with which the health plan has a pre-existing business arrangement. In such cases, the health plan, upon receiving notice of the employee’s election of the preferred HSA vendor, would communicate the information to the HSA vendor necessary to set up the account. In other cases, the selection and establishment of the HSA might take place “out of channel” directly between the employee and the financial institution. An HSAVendor element within the Tier Coverage component allows for the transmission information necessary to accommodate these contingencies.
4.15 Dependent Life Enrollments
Some dependent life enrollments are only captured as they relate to the subscriber. For example, one may capture the fact that a subscriber has a dependent life plan for $10,000 but actual dependent information may not exist. On the other hand, a subscriber may enroll the dependent with explicit dependent information. The schema accommodates both scenarios and examples for each appear in section 7.9.
4.16 Optional Information – not known by source system
If an optional element is not known/captured by the source system, the corresponding tags and/or content SHOULD NOT be sent in the payload.
4.17 Required Date Information – not known by source system
If the source system does not store a required date, but a “notKnown” enumeration is defined, ‘notKnown’ SHOULD be sent instead of a default date. A trading partner agreement is required if a date is required, but the sender is not able to provide it.
4.18 Current vs. Historical Tier Coverage
It is RECOMMENDED that the source system sends only the most current TierCoverage instance for a subscriber/dependent, unless there is a change to historical coverage data (i.e.: revised effective date). For changes to historical coverage information, the source system SHOULD send all TierCoverage instances from the point of change through the most current coverage. Receiving systems SHOULD use the data provided to overlay historical and current coverage, beginning with the most historical coverage sent. The receiving system SHOULD sort all Tier Coverage instances as needed for processing.
4.19 Contact Information Use
It is RECOMMENDED that the source system sends the Use element (business, businessDirect, personal) to describe Contact Information whenever it is known. If Use information is not known, it SHOULD NOT be sent/defaulted by the sender. In this case, the receiving system MUST have business rules defined to facilitate processing of Contact Information.
5 Appendix A - Document Version History
|
Date |
Description |
|
2001-Oct-16 |
Approved Recommendation by HR-XML Consortium |
|
2003-Feb-26 |
Approved recommendation by HR-XML Consortium. The default and targetNamespaces of all HR-XML schemas have been standardized to "http://ns.hr-xml.org". This recommendation is available as part of the HR-XML 2_0 architecture.
|
|
2004-Apr-05 |
Made backwards compatible changes based on implementor and benefit testing feedback. See overview section for details. Separated Enrollment document into two documents. The second doc contains all of the examples. |
|
2004-May-14 |
Renamed MailingAddress to PostalAddress and EligibilityState to EligibilityRegion. Changed UniquePayloadTrackingId to an element. Extended coverageLevelCode and productType enumerations. Updated diagrams and definition tables as needed. Based on CPO feedback. |
|
2004-May-24 |
Corrected overview section, added Enumerations table – based on TSC feedback. |
|
2004-Jun-07 |
Updated survivorship implementation guidelines based on Benetest feedback. Added clarification regarding non-backwards compatible and other changes; updated tables to reflect multiple occurrences for ContactInfo. An optional attribute xml:lang was added to the root element. |
|
2004-08-02 |
Approved by Membership. |
|
2005-04-05 |
Schema changes: · Changed reusable structures to complex types. Moved to EnrollmentTypes schema, when appropriate. · Moved generic coverage types to Localizations schema.</ |