PEBTF 834 5010 Outgoing Eligibility
PEBTF Outgoing Eligibility v5010 Benefit and Enrollment Maintenance 834
1 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Table of Contents What changed from 4010 to 5010 in this Guide
5
Segment: ISA - Interchange Control Header
6
Segment: GS – Functional Group Header
7
Segment: ST – Transaction Set Header
7
Segment: BGN – Beginning Segment
7
Segment: REF – Transaction Set Policy Number
8
Segment: DTP – File Effective Date
8
LOOP ID - 1000A Segment: N1 – Sponsor
8
LOOP ID – 1000B Segment: N1 – Payer
9
LOOP ID – 2000 Segment: Segment: Segment: Segment: Segment:
INS – Member Level Detail REF – Subscriber Number REF – Member Policy Number REF - Member Identification Number DTP - Member Level Dates
LOOP ID - 2100A Segment: Segment: Segment: Segment: Segment:
NM1 - Member Name PER - Member Communications Numbers N3 - Member Residence Street Address N4 - Member Residence City, State, Zip Code DMG - Member Demographics
9 10 10 11 11
12 12 13 13 13
LOOP ID - 2100B Segment: NM1 - Incorrect Member Name Segment: DMG - Incorrect Member Demographics
14 14
LOOP ID 2100C Segment: NM1 - Member Mailing Address Segment: N3 - Member Mail Street Address Segment: N4 - Member Mail City, State, Zip Code
14 15 15
LOOP ID 2200 Segment: DSB- Disability Information Segment: DSB - Disability Eligibility Dates
15 16
LOOP ID - 2300 Segment: HD - Health Coverage Segment: DTP - Health Coverage Dates
16 17
LOOP ID 2310 Segment: LX - Provider Information
17 2
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PEBTF 834 5010 Outgoing Eligibility
Segment: NM1- Provider Name Segment: PLA - Provider Change Reason
17 18
LOOP ID 2300 Segment: COB - Coordination of Benefits
18
Segment SE - Transaction Set Trailer
19
Segment GE - Functional Group Trailer
19
Segment IEA - Interchange Control Trailer
19
Reference Tables Member Status Code Values (Status codes are for informational purposes only)
20
Commonwealth Bargaining Units
27
County Codes ACTIVE/ RETIREE
31
Group Codes
33
Rider Codes
42
Dependent Status Codes
43
Plan Codes
45
Relationship Codes
50
Department Codes
51
Attachment Subscriber/Dependent Suffix Values
53
3 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
PEBTF 834 DATA ELEMENT GUIDELINES Benefit Enrollment and Maintenance The Pennsylvania Employees Benefit Trust Fund (PEBTF) has created this guide to assist Health Care Plans receiving electronic eligibility transmissions in the HIPAA ANSI-X12 5010 standard format for 834 transactions. This document includes some data elements and values that will be utilized by the PEBTF to assist in processing files but does not contain an explanation for all HIPAA required and situational elements. Further definitions of field formats should be obtained from the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 for Benefit Enrollment and Maintenance (834). Additional information pertaining to delivery of transactions can be found in the PEBTF EDI Companion Document on the Health Plans Only publications page of our website at www.pebtf.org. PEBTF will provide two types of EDI files: 1. Change/Update file – to include maintenance eligibility for members with one or more changes. If the change involves correcting historical periods, these periods of coverage will be included. Historical changes will be identified with 026 (correction) in the HD01 element. If a member’s activity involves a termination then reinstatement, it is possible to receive multiple records for that member in a single transaction. 2. Verify/Audit file – to include current full enrollment. A corresponding Functional Acknowledgement 999 is expected to be received for each daily and quarterly production 834 transmitted. The values defined in this document may be expanded to incorporate additional HIPAA values as further requirements necessitates. Revisions: Date 4/21/2011 10/13/2011 (jw)
01/19/2012 (DR) 05/16/2012 07/03/2012 10/23/2012 11/02/12 12/13/2012
Revision Initial v5010 implementation. 1. Change Standards document name to …Technical Report Type 3. 2. Loop 2000 INS05 – remove S (Survivor Spouse) 3. Loop 2310 Provider NM108 and NM109 – data elements will be excluded since NPI is not available to send. 4. Loop 2320 COB added. 1. CE status code added 2. Department 0074 added 3. Plan TPA and TPB added Add Loop 2000 DTP*300 Enrollment Signature Date Added bargaining units for PGCB Added Department 0084 PA E-Health Partnership Authority and several new status codes Added bargaining unit X4 for PHEAA – new riders for Medicare Part D plan and DD dependent Status code for disabled dependent termed March 2013 Added Plans M28,S28,M60 and S60 Aetna plans 4
Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
What changed from 4010 to 5010 in this Guide: Loop/Segment Description ISA11 Data element use changed to a Repetition Separator with a value = Carat (^). Old value = U ISA12 Value changed from 00401 to 00501 for the interchange control version number GS08 004010X095A1 changed to 005010X220A1 ST03 Add new data element = 005010X220A1 for the implementation convention reference Loop 1000A-N103 Change sponsor identification code qualifier from ZZ to 94 Loop 2000 – INS02 Remove relationship code 23. Change relationship code from 38 to 19 for disabled dependent. Loop 2000 – INS09 Remove student status code Loop 2000 – INS10 Add disability indicator; value = Y Loop 2100A – PER** Add CP cellular phone communication number qualifier Loop 2100A – HLH Remove member health information segment Loop 2300 – HD03 Remove the MOD and POS insurance line codes Loop 2300 – HD05 Add coverage level = DEP for dependents only Loop 2310 – LX Remove PCP disclaimer as being under development Loop 2310 – NM101 Remove entity identifier code QN for dentist Loop 2310 – NM108 Remove identification code qualifier XX for national provider ID Loop 2310 – NM110 List available entity relationship codes Loop 2310 – N4 Remove provider city, state, zip code segment Loop 2310 – PLA05 List available maintenance reason codes
5 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Segment:
ISA – Interchange Control Header
Reference Designator ISA01
Element Name Authorization Information Qualifier
Element Note Value = 00 (No authorization information present)
ISA02
Authorization Information
Space filled
ISA03
Security Information Qualifier
ISA04
Security Information
Value = 00 (No security information present) unless trading partner requires security information Space filled
ISA05
Interchange ID Qualifier
Values to be used:
30 (Federal Tax ID) ZZ (Mutually defined) PEBTF’s Tax ID or other value as required by trading partner
ISA06
Interchange Sender ID
ISA07
Interchange ID Qualifier
ISA08
Interchange Receiver ID
ISA09
Interchange Date
Receiver ID qualifier values: 01 (DUNS Number) 30 (U.S. Federal Tax ID) 33 (NAIC) ZZ (Mutually defined) Health Plan’s Tax ID, NAIC, DUNS, or mutually defined value to correspond to the ISA07 qualifier System Date
ISA10
Interchange Time
System Time
ISA11
Repetition Separator
Value = ^
ISA12
Interchange Control Version Number
Value = 00501
ISA13
Interchange Control Number
Application assigned sequence number
ISA14
Acknowledgment Requested
Value = 0 (No Acknowledgment Requested)
ISA15
Usage Indicator
Transmission usage values: P (Production Data) T (Test Data)
ISA16
Component Element Separator
Values to be used:
: (colon) > (greater than if requested by trading partner)
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PEBTF 834 5010 Outgoing Eligibility
Segment:
GS – Functional Group Header
Reference Designator GS01
Functional Identifier Code
Element Note Value = BE (Benefit Enrollment and Maintenance – 834)
GS02
Application Sender’s Code
Same as ISA06 or Mutually defined code
GS03
Application Receiver’s Code
Same as ISA08 or Mutually defined code
GS04
Date
System Date
GS05
Time
System Time
GS06
Group Control Number
Application assigned sequence number
GS07
Responsible Agency Code
Value = X (Accredited Standards Committee X12)
GS08
Version/Release/Industry Identifier Code
Value = 005010X220A1
Segment:
Element Name
ST – Transaction Set Header
Reference Designator ST01
Transaction Set Identifier Code
Element Note Value = 834
ST02
Transaction Set Control Number
Application assigned sequence number
ST03
Implementation Convention Reference
Value = 005010X220A1
Segment:
Element Name
BGN – Beginning Segment
Reference Designator BGN01
Transaction Set Purpose Code
Element Note Value = 00 (Original)
BGN02
Transaction Set Identifier Code
Application assigned reference number
BGN03
Date
System Date
Element Name
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PEBTF 834 5010 Outgoing Eligibility
BGN04
Time
System Time
BGN05
Time Code
Value = ES (Eastern Standard Time)
BGN08
Action Code
Values: 2 (Change/Update) 4 (Verify/Full Enrollment)
Segment:
REF – Transaction Set Policy Number
Reference Designator REF01
Reference Identification Qualifier
REF02
Subscriber Identifier
Segment:
Element Name
Element Note Value = 38 (Master Policy Nbr) Health plan specific value associated with entire file.
DTP – File Effective Date
Reference Designator DTP01
Reference Identification Qualifier
Element Note Value = 007 (Effective)
DTP02
Date Time Period Format Qualifier
Value = D8
DTP03
Status Information Effective Date
Health plan specific date
Element Name
LOOP ID – 1000A Segment:
N1 – Sponsor
Reference Designator N101
Entity Identifier Code
N102
Name
Value = Commonwealth of PA and Unions et al
N103
Identification Code Qualifier
94 (Code designating destination)
N104
Identification Code
Value = 100188521 (This value may change to the EIN, then N103 would change to 24.)
Element Name
Element Note Value = P5 (Plan Sponsor)
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PEBTF 834 5010 Outgoing Eligibility
LOOP ID – 1000B Segment:
N1 – Payer
Reference Designator N101
Entity Identifier Code
Element Note Value = IN (Insurer)
N102
Name
Health Plan’s Name
N103
Identification Code Qualifier
Value = FI (Federal Tax ID)
N104
Identification Code
Health Plan’s Tax ID
Element Name
LOOP ID – 2000 Segment:
INS – Member Level Detail
Reference Designator INS01
Yes/No Condition or Response Code
INS02
Individual Relationship Code
INS03
Maintenance Type Code
Element Name
Element Note Subscriber indicator values: Y (yes) N (no) Values to be used:
01 03 05 07 08 10 14 15 17 18 19 19 19 19 53
-
SPOUSE DEPEND. PARENT (RX ONLY) GRANDCHILD NIECE/NEPHEW COUSIN FOSTER CHILD BROTHER/SISTER LEGAL WARD STEP CHILD EMPLOYEE DEPENDENT WITH QMCSO NATURAL/ADOPTED CHILD NEWBORN FIRST 31 DAYS DISABLED DEPENDENT DOMESTIC PARTNER
Values to be used:
001 021 024 025 030
INS04
Maintenance Reason Code
(Change) (Addition) (Termination/Cancellation) (Reinstatement) (Audit/Compare) Values to be used: 03 (Death) 07 (Term) 20 (Active) 22 (Plan change) 28 (Initial Enrollment) 43 (Address change) 9
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PEBTF 834 5010 Outgoing Eligibility
XN (Audit file value) INS05
Benefit Status Code
Value to be used:
A (Active) INS06
Medicare Plan Code
Values to be used:
A (Medicare part A) B (Medicare part B) C (Medicare part A and B) INS07
COBRA Qualifying
Values to be used: 1 (Termination
2 4 5 7
of employment) (Reduction of work hours) (Death) (Divorce) (Ineligible child)
Employment Status Code
Values to be used for subscriber only:
INS10
Yes/No Condition/Response Code
FT (Full-time) L1 (Leave of Absence) PT (Part-time) RT (Retired) TE (Terminated) Value = Y (Disabled member)
INS11
Date Time Period Format Qualifier
Value = D8 (ccyymmdd)
INS12
Date Time Period
Deceased Date
INS08
LOOP ID – 2000 Segment:
REF – Subscriber Number
Reference Designator REF01
Reference Identification Qualifier
Element Note Value = 0F (Subscriber number)
REF02
Subscriber Identifier
Subscriber SSN
Element Name
LOOP ID – 2000 Segment:
REF – Member Policy Number
Reference Designator REF01
Reference Identification Qualifier
REF02
Insured Group or Policy Number
Element Name
Element Note Value = 1L (Group or policy number) Value to be assigned by trading partner but will default to our group, subgroup, and plan if not provided. 10
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PEBTF 834 5010 Outgoing Eligibility
LOOP ID – 2000 Segment: Reference Designator REF01
REF02
REF – Member Identification Number Element Name
Element Note
Reference Identification Qualifier
Values to be used:
Subscriber Supplemental Identifier
F6 (HIC number) 23 (Person number) 17 (Client reporting category) DX (Dept, agency, division) ZZ (Mutually Defined) If qualifier F6, then the Health Insurance Claim number is entered. If qualifier 23, then the person number values are: 01 = Subscriber 02 = Spouse 03 = Dependent 04 = Dependent etc. through 24 = Dependent 25 = Spouse2 26 = Spouse3 etc. through 99 = Spouse76 If qualifier 17, then will contain values as required by plan. (Not to appear in all files.) If qualifier DX, then value to consist of 15-digit code as follows: Positions 1-6 = Group number Positions 7-9 = Subgroup code Positions 10-12 = Plan code Positions 13-14 = Bargaining unit Position 15 = Plan type If qualifier ZZ, then will contain PEBTF de-identification number. (Not to appear in all files.)
LOOP ID – 2000 Segment: Reference Designator DTP01
DTP02
DTP – Member Level Dates Element Name
Element Note
Reference Identification Qualifier
Values to be used:
Date Time Period Format Qualifier
300 (Enrollment Signature Date) 338 (Medicare begin) 356 (Eligibility begin) 357 (Eligibility end) Value = D8
11 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
DTP03
Status Information Effective Date
Date associated with value in DTP01
LOOP ID – 2100A Segment: Reference Designator NM101
NM1 – Member Name Element Name
Element Note
Entity Identifier Code
Values to be used:
NM102
Entity Type Qualifier
IL (Insured or Subscriber) 74 (Corrected insured name) Value = 1 (Person)
NM103
Name Last or Organization Name
NM104
Name First
NM105
Name Middle
NM107
Name Suffix
NM108
Identification Code Qualifier
Value = 34 (Social security number)
NM109
Identification Code
Member’s SSN
LOOP ID – 2100A Segment:
PER – Member Communications Numbers
Reference Designator PER01
Contact Function Code
PER03
Communication Number Qualifier
Element Name
Element Note Value = IP (Insured party) Values to be used as available for PER03, PER05, and PER07):
HP (Home phone number) WP (Work phone number) CP (Cellular phone number) PER04
Communication Number
PER05
Communication Number Qualifier
PER06
Communication Number
12 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
PER07
Communication Number Qualifier
PER08
Communication Number
LOOP ID – 2100A Segment:
N3 – Member Residence Street Address
Reference Designator N301
Address Information
N302
Address Information
Element Name
Element Note
LOOP ID – 2100A Segment:
N4 – Member Residence City, State, Zip Code
Reference Designator N401
City Name
N402
State or Province Code
N403
Postal Code
N404
Country Code
N405
Location Qualifier
Element Name
Element Note
Value to be used for subscriber only:
Value = CY (County) N406
Location Identifier
County Code (3-digits)
LOOP ID – 2100A Segment:
DMG – Member Demographics
Reference Designator DMG01
Date Time Period Format Qualifier
Element Note Value = D8 (CCYYMMDD)
DMG02
Date Time Period
Member’s Birth Date
Element Name
13 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
DMG03
Gender Code
Values to be used:
F (Female) M (Male) DMG04
Marital Status Code
Values to be used for subscriber only:
M (Married) I (Single) B (Registered Domestic Partner)
LOOP ID – 2100B Segment:
NM1 – Incorrect Member Name
Reference Designator NM101
Entity Identifier Code
Element Note Value = 70 (Prior incorrect insured)
NM102
Entity Type Qualifier
Value = 1 (Person)
NM103
Name Last or Organization Name
Prior/incorrect last name
NM104
Name First
Prior/incorrect first name
NM105
Name Middle
Prior/incorrect middle initial
NM107
Name Suffix
Prior/incorrect suffix
Element Name
LOOP ID – 2100B Segment:
DMG – Incorrect Member Demographics
Reference Designator DMG01
Date Time Period Format Qualifier
Element Note Value = D8 (ccyymmdd)
DMG02
Date Time Period
Prior incorrect birth date
DMG03
Gender Code
Prior incorrect gender code
Element Name
LOOP ID – 2100C Segment: Reference Designator
NM1 – Member Mailing Address Element Name
Element Note 14
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PEBTF 834 5010 Outgoing Eligibility
NM101
Entity Identifier Code
Value = 31 (Postal Mailing Address)
NM102
Entity Type Code
Value = 1 (Person)
LOOP ID – 2100C Segment:
N3 – Member Mail Street Address
Reference Designator N301
Address Information
N302
Address Information
Element Name
Element Note
LOOP ID – 2100C Segment:
N4 – Member Mail City, State, Zip Code
Reference Designator N401
City Name
N402
State or Province Code
N403
Postal Code
N404
Country Code
Element Name
Element Note
LOOP ID – 2200 Segment:
DSB – Disability Information
Reference Designator DSB01
Disability Type Code
DSB07
Product/Service ID Qualifier
DSB08
Medical Code Value
Element Name
Element Note Value = 2 (Long Term Disability Value = DX (International Classification of Diseases Clinical Modification (ICD9-CM) – Diagnosis Value = 585 (End Stage Renal Disease
15 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
LOOP ID – 2200 Segment: Reference Designator DTP01
DSB – Disability Eligibility Dates Element Name
Element Note
Date/Time Qualifier
Values to be used:
360 – Disability Begin 361 – Disability End DTP02
Date Time Period Format Qualifier
Value = D8
DTP03
Date Time Period
Date associated with DTP01 value
LOOP ID – 2300 Segment: Reference Designator HD01
HD – Health Coverage Element Name
Element Note
Maintenance Type Code
Values to be used:
001 021 024 025 026 030 HD03
Insurance Line Code
HD04
Plan Coverage Description
HD05
Coverage Level Code
(Change) (Addition) (Cancellation/Termination) (Reinstatement) (Correction) (Audit/Compare)
Values to be used:
AJ – Medicare Risk DCP – Dental Capitation DEN – Dental HLT – Health HMO – Health Maintenance Org PDG – Prescription Drug PPO – Preferred Provider Org VIS – Vision (For the CMM plan, the value will be HLT.) Plan code (3-digits) or other value as required by trading partner Values to be used for subscriber only:
EMP – Employee only ESP – Employee and spouse ECH – Employee and children FAM – Family DEP – Dependents only (Used when a subscriber is ineligible for the line of benefit but their information is needed to enroll the dependent.)
16 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
LOOP ID – 2300 Segment: Reference Designator DTP01
DTP – Health Coverage Dates Element Name
Element Note
Date/Time Qualifier
Values to be used:
DTP02
Date Time Period Format Qualifier
303 – Maintenance Effective 348 – Benefit Begin 349 – Benefit End Value = D8
DTP03
Date Time Period
Date associated with DTP01 value
LOOP ID – 2310 Segment: Reference Designator LX01
LX – Provider Information Element Name Assigned Number
Element Note Sequential number
LOOP ID – 2310 Segment: Reference Designator NM101
NM1 – Provider Name Element Name
Element Note
Entity Identifier Code
Value to be used:
P3 (Primary Care Provider) NM102
Entity Type Qualifier
NM103
Name Last or Organization Name
NM104
Name First
NM105
Name Middle
NM107
Name Suffix
NM108
Identification Code Qualifier
NPI not available to send
NM109
Provider Identifier
NPI not available to send
17 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
NM110
Entity Relationship Code
Values to be used:
25 - Established Patient 26 – Not Established Patient 72 – Unknown
LOOP ID – 2310 Segment:
PLA – PCP Change Reason
Reference Designator PLA01
Action Code
Element Note Value = 2 (Change/Update)
PLA02
Entity Identifier Code
Value = 1P (Provider)
PLA03
Provider Effective Date
The effective date of the change of PCP.
PLA05
Maintenance Reason Code
Element Name
Values to be used:
14 – Voluntary Withdrawal 22 – Plan Change 46 – Current Customer Information file in Error AA – Dissatisfaction with Office Staff AB – Dissatisfaction with Medical Care/Services Rendered AC – Inconvenient Office Location AD – Dissatisfaction with Office Hours AE – Unable to Schedule Appt. in a timely manner AF – Dissatisfaction with Physician’s Referral Policy AG – Less Respect and Attention time given than to other patients AH – Patient Moved to a New Location AI – No reason given) AJ – Appt times not met in a timely manner
LOOP ID – 2320 Segment:
COB – Coordination of Benefits
Reference Designator COB01
Payor Responsibility Seq# Code
Element Note Value = U (Unknown)
COB03
Coordination of Benefits
Value = 1 (Coordination of Benefits)
COB04
Service Type Code
Value = 1 (Medical Care)
Element Name
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PEBTF 834 5010 Outgoing Eligibility
Segment:
SE – Transaction Set Trailer
Reference Designator SE01
Number of Included Segments
Element Note Transaction segment count
SE02
Transaction Set Control Number
Same value as ST02
Segment:
Element Name
GE – Functional Group Trailer
Reference Designator GE01
Number of Transaction Sets Included
Element Note Transaction set count
GE02
Group Control Number
Same value as GS06
Segment:
Element Name
IEA – Interchange Control Trailer
Reference Designator IEA01
Number of Included Functional Groups
Element Note Functional group count
IEA02
Interchange Control Number
Same value as ISA13
Element Name
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PEBTF 834 5010 Outgoing Eligibility
Member Status Code Values (Status codes are for informational purposes only) Status Code/ Barg Unit 00 00
Benefit Eligibility Medical All RX Sup Only Y Y Y Y
00
N
N
00/L6
Y
N
00/R4 Demo 3 equals PR2 02
Y
N
Y
Y
03
N
N
04
Y
Y
05
N
07
Offer Further Coverage COBRA
HIPAA
X
X
N
X
X
N
N
X
X
08
N
N
X
X
09
N
N
X
X
Definition
SURVIV SPOUSE
Full-time active employee Part-time active employee, eligible if working at least 50% of full-time hours (TWC 150 – 100 or 350 – 300) If employee drops below 50% (TWC = 101 – 149 or 301 – 349) they are not eligible State Police Cadets – bargaining unit L6 – No Supplemental benefits Part-time Park Rangers (PR2) in bargaining unit R4 with PR2 in “Demo 3” field eligible to purchase Medical coverage only Active employee on leave without pay with benefits, eligible for 6 months (12 months in certain circumstances) Active employee on leave without pay without benefits, eligible for 365 days. COBRA qualifying event. Active employee on Military leave without pay with benefits. Active employee on Military leave without pay without benefits. Employee terminated employment. COBRA qualifying event. Employee terminated as a result of furlough/involuntary termination. Deceased employee. COBRA qualifying event. If death is work related, spouse and dependents may remain eligible for active benefits at no cost provided they do not remarry, do not become eligible for other health coverage and annually certify. Enrollment in REHP occurs at the time the employee would have been eligible for those benefits. Surviving spouses of employees whose deaths are not work related may also be eligible for the survivor spouse benefit under REHP provided the employee was eligible for retirement the day before their death. Dependents are not eligible for the survivor spouse benefit but would be eligible for COBRA
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PEBTF 834 5010 Outgoing Eligibility
Status Code/ Barg Unit
Benefit Eligibility Medical
RX Only
Offer Further Coverage COBRA
HIPAA
10
Y
All Sup Y
11
N
N
X
13
N
N
X
15
N
N
16
Y
Y
16/M1
Y
N
17
N
N
18
Y
N
20 21 22
Y N Y
Y N Y
23 25
N Y
N N
26
Y
N
X
X
X
X
X
X
Definition
SURV SPOUSE
Active employee on a workers comp leave, eligible for 365 days unless employed by department 021 or 011. If employee is injured by an inpatient or inmate and an Act 534, 632 or Heart and Lung, employee remains on a 10 status indefinitely. Active employee terminated for Gross Misconduct, employee is not eligible for COBRA. Member on 02 or 10 status termed for delinquency.
Chose no PEBTF coverage Medical and Supplemental Active PEBTF staff, Wood Dining Group (Position) Liquor Store Clerks, bargaining unit M1, who satisfy a 978 hour waiting period – medical benefits only (No supplemental benefits) SSHE and PSP. SSHE bargaining units Q4, U4, O4, 91 and 92 no longer participate with the PEBTF. The PEBTF continues to generate COBRA for PSP participants with a status code 17. Liquor store clerks who do not satisfy the 978 hour waiting period requirement. PEBTF participant/medical coverage only Intermittent Intake Interviewer (III) III ineligible Energy Assistance Worker (EAW) – active employee (w/ Sup Ben only – medical cov elig only if position was taken to avoid furlough from another position) Ineligible EAW Leave without pay, with benefits/Medical coverage only (Member had Medical coverage only, prior to leave)
Workers Comp leave medical coverage only
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PEBTF 834 5010 Outgoing Eligibility
Status Code/ Barg Unit
Benefit Eligibility Medical
27
N
All Supp Y
28
N
Y
30
Y
Y/N
31
Y
Y/N
32
N
Y/N
33
Y
Y/N
34
Y
Y/N
35
Y
36 37
Y Y
Y/N
Offer Further Coverage RX Only
COBRA
HIPAA
Definition
SURV SPOUSE Leave without pay, with benefits/Supplemental Benefits Only (Member had Supplemental Benefits Only, prior to leave) Worker’s Compensation leave/Supplemental Benefits only (Member had Supplemental benefits only, prior to WC leave) COBRA participant – QE divorce Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. COBRA participant – QE dependent who is no longer eligible under the PEBTF Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. COBRA participant – Disability retirement canceled Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. COBRA participant – QE leave without pay without benefits Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. COBRA participant – QE reduction in hours Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. Military – USERRA coverage (24 months) Military – State mandated coverage COBRA participant – QE termination, furlough Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage.
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PEBTF 834 5010 Outgoing Eligibility
Status Code/ Barg Unit
Benefit Eligibility Medical
RX Only
Offer Further Coverage COBRA
HIPAA
38
Y
All Sup Y/N
39
Y
Y/N
40 41 50 51 52 53
N Y Y Y Y N
N Y N N N N
X
X X
X
X
57 58
N N
N N
X X
X X
59 60 62 63
N N Y Y
N N Y Y
X
X X
64
N
N
69
Y
Y
80
Y
N
81
N
N
91
N
Y
99
N
N
CE
Y
Y
X
X
X
X
Definition
SURVIV SPOUSE
X
COBRA participant – QE Involuntary Termination/Furlough COBRA participant – QE death Sup Ben elig determined by what the member had prior to qualifying event and then whether they elect supplemental coverage. Ineligible COBRA participant NOT USED – REMOVED Annuitant Disabled annuitant REHP Survivor Spouse Annuitant covered under their spouses active contract Retirement discontinued per SERS Disability retirement discontinued per SERS Annuitant deceased Annuitant not eligible Inactive employee with benefits Suspect abuse – Family restricted to mail order All benefits suspended for Fraud/Abuse Suspect Abuse – Family restricted to one pharmacy – internal use only Family suspended for supplemental benefits – owe $ - internal use only Family suspended for all benefits – owe $ internal use only PEBTF participant eligible for supplemental benefits only. This Status Code no longer used. It referred to termination of free Supplemental COBRA coverage under the Survivor benefit. COBRA secondary qualifying event coverage extended
23 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Member Status Code Values in 2nd status code field Internal use only Status Code/ Barg Unit AB
Benefit Eligibility Medical All Sup RX Only Y Y
A1
Y
Y
A2
Y
Y
BL
Y
Y
BM
Y
Y
BR
Y
Y
ES FO
Y
Y
FM
N
N
FR
N
N
HO HP
N Y
N Y
ME
Y
Y
MR
N
N
MS
Y
N
NA
Y
Y
NB
Y
Y
NS OB
Y Y
Y Y
DQ
COBRA
Offer Further Coverage HIPAA Survivor Spouse
Definition
Not Eligible for Medicare Part A/B RSP affirmation retired prior to 11/15/1983 RSP affirmation retired 11/15/1983-06/30/2000 Black Lung REHP Mbr opting back into Medical coverage REHP Mbr opting back into RX coverage Billable Member Terminated for Delinquency Member ESRD REHP Final Opt of medical and RX REHP Mbr final medical coverage opt out REHP Mbr final RX Coverage opt out Health Oversight Hospice – with less than 6 months to live Medicare extension, member applied for part B REHP Member opted out of Medical & RX Aetna Medicare supplemental temp plan Not Eligible for Medicare Part A Not Eligible for Medicare Part B No SSN REHP Mbr opting back into Medical coverage and RX
24 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Status Code/ Barg Unit
Benefit Eligibility Medical
All Sup
OC OM
Y N
Y Y
OR
Y
N
N
N
Y
Y
RR SP TT
Y Y Y
Y Y N
TV
Y
N
UC
Y
Y
UM
Y
Y
WI
Y
WY
Y
XX
Y
OS OX PD PE PO RP
Y
8D
8N
8S
Offer Further Coverage RX Only
COBRA
HIPAA
Definition
Survivor Spouse Other Coverage REHP member opted out of Medical REHP member opted out of RX Member Resides Out of State/MPFFS Exception REHP member opted out of all coverage Member Paid Delinquent Premiums Provider Exceptions (out of state only) PEBTF Opted REHP Member Out of Medical Member Opt Out – Other Coverage – Med Remed Project Railroad Retirement RSP & REHP coverage REHP medical only with Tricare prescription cvrg REHP medical only with VA prescription coverage Unique Condition Exceptions United Mine Workers of America Workers Comp LeavePEBTF Benefits indefinite period Workers Comp Leave – PEBTF Benefits up to one year Out of Country (except Guam, Samoa, Virgin Islands & Puerto Rico) PEBTF/CMS Mismatch – MBR must correct or RX only Member Rec’d 8 series LTR/Did not elect Medicare 8 Series letter – MBR must ENRL in Med PT B
25 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Member Status Code Values in 3rd status code field Internal use only Status Code/ Barg Unit TP
Benefit Eligibility Medical
All Sup
Y
Offer Further Coverage RX Only
COBRA
HIPAA
Definition
Survivor Spouse REHP Medical only as exception
26 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Commonwealth Bargaining Units Bargaining Unit
Description
Employee Representation
A1 A2 A3 A4 A5 A6 A8 A9 B1 B2 B3 B4 B5 B6 C3 C4 C5 C6 D3 D4 E4 F1 F2 F3 F4 F5 F6 G1
Clerical, Administrative & Fiscal Clerical, Administrative & Fiscal Clerical, Administrative & Fiscal Professional, Administrative & Fiscal Professional, Administrative & Fiscal General Non Supervisory Master Agreement Executive (Management) General Supervisory Master Memorandum Technical Services Technical Services Technical Services & Engineering & Scientific Engineering & Scientific Engineering & Scientific Technical Services & Engineering & Scientific Educational & Cultural Educational & Cultural Educational & Cultural Educational & Cultural Instructional Tenured Instructional Tenured Adult Correction Education Unit Social & Rehabilitative Services Social & Rehabilitative Services Social & Rehabilitative Services Social & Rehabilitative Services Social & Rehabilitative Services Social & Rehabilitative Services Inspection, Investigation & Safety
AFSCME AFSCME MGT AFSCME MGT MGT AFSCME AFSCME MGT AFSCME MGT MGT MGT FOSCEP FOSCEP MGT MGT PSEA CIVEA PESEA/PSSU PESEA/PSSU MGT PESEA/PSSU PESEA/PSSU MGT AFSCME
27 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Bargaining Unit
Description
Employee Representation
G2 G3 G4 G5 H1 H2 H3 I5 J1 J2 J3 K1 K2 K3 K4 K5 K6 K7 K8 L1 L3 L4 L6 M1 M2 M3 M8 N1 N2 N3 O4
Inspection, Investigation & Safety Inspection, Investigation & Safety Inspection, Investigation & Safety Inspection, Investigation & Safety Corrections Officers & Psychiatric Security Aides Psychiatric Security Aides Corrections Officers & Psychiatric Security Aides Hearing Officers Maintenance & Trades Maintenance & Trades Maintenance & Trades Waterway Conservation Officers Waterway Conservation Officers Law Enforcement (Liquor, Fish & Game Laws) Law Enforcement (Liquor Laws) Law Enforcement (Liquor Laws) Law Enforcement (Fish & Game Laws) Law Enforcement (Fish & Game Laws) Law Enforcement (Fish & Game Laws) State Police State Police Capitol Police State Police Cadets Liquor Store Clerks Liquor Store Managers State Store Management Liquor Store General Manager Human Services Human Services Human Services State University Administration
AFSCME MGT AFSCME AFSCME AFSCME AFSCME MGT PSSU AFSCME AFSCME MGT AFSCME AFSCME MGT FOP-LCB PLCB-EOIII MGT AFSCME AFSCME FOP-SP MGT UFCW ISSU MGT MGT AFSCME AFSCME MGT SSHE
28 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Bargaining Unit
Description
Employee Representation
P3 P4 P5 P7 Q3 Q4 Q8 R1 R2 R3 R4 S3 S4 S5 T3 T4 T5 T6 U4
Nursing & Supportive Medical Services Nursing & Supportive Medical Services Nursing & Supportive Medical Services PRN Nurses – not covered by PEBTF
MGT PNA PNA PNA MGT SSHE SSHE UPGWA UPGWA MGT PSPOA MGT SSH/PFT MGT MGT PASMHP PASMHP MGT SSHE
V1 V2 V3 V4 V8 V9 W1 W2 W3 W4 W5 W7 W8 W9 X1 X3 X4 Y1 Y3 Y4 Z3 Z4 Z5 22 30
State University Faculty – not covered by PEBTF SSHE Policy Executives – not covered by PEBTF Security Security Security Park Rangers Instructional, Non-Tenured Instructional, Non-Tenured Instructional, Non-Tenured Physicians & Related Occupations Physicians & Related Occupations Physicians & Related Occupations Physicians & Related Occupations State University Administration – not covered by PEBTF Treasury Administration Treasury – Clerical, Fiscal, Admin Treasury Treasury – Admin, Fiscal Treasury – Custodial Treasury Investigator Auditor General – Clerical Serv Auditor General – Supervisors Auditor General – Management Auditor General – Fiscal Audit Auditor General – Fiscal Audit Auditor General – Inspector, Investigator Auditor General – Building Services Auditor General – Inspector, Investigator PHEAA – Clerical, Admin, Gen Servs PHEAA – Management PHEAA – Seaport Staff Public School Building Authority – Clerical Public School Building Authority – Management Public School Building Authority – Engineering Public Utility Commission – Management PUC Assistant Counsels PUC Assistant Counsels PA Employees Benefit Trust Fund Survivor Spouse & PSP Ann w/o Dental Coverage
AFSCME AFSCME MGT AFSCME AFSCME AFSCME AFSCME AFSCME MGT AFSCME AFSCME AFSCME AFSCME AFSCME AFSCME MGT AFSCME MGT AFSCME MGT MGT MGT
29 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
31 Bargaining Unit
Survivor Spouse – 919009 Description
32 33 34 35 37 53 54 55 60 61
Survivor Spouse – 919012 Survivor Spouse – 919013 Survivor Spouse – 919014 Survivor Spouse – 919005 Survivor Spouse – 919795, 919704, 919405 Philadelphia Regional Port Authority Philadelphia Regional Port Authority PA Intergovernmental Cooperation Authority State Police Annuitants State Police Annuitants Retired after 7/1/83 PGCB Non-Prof/Non-Supv State Police Annuitants Retired after 1/1/86 State Police Annuitants Retired after 7/1/86 PGCB State Police Annuitants Retired after 7/1/88 PGCB Prof/Non-Supv Fully-Pd and Deduction Annuitants PGCB Prof/Supv Deduction Annuitants retired after 7/1/90 PSP Annuitant retired after 7/1/95, 7/1/04, 04/21/05 PGCB unclassified SSHE Annuitants Trans Retro and Termed 7/1/92 PGCB Executive Public School Annuitants TIACREF Direct – Bill Annuitants Direct – Bill Annuitants retired after 7/1/90 Housing Finance Management Emp Pending Disability Ret Approval SSHE – Management – not covered by PEBTF SSHE – Coaches – not covered by PEBTF Contractual Municipal Employees U-Coded Employees w/o Mgt Benefits U-Coded Employees w/o Mgt Benefits
62 63 64 65 66 67 68 69 70 75 76 82 85 91 92 94 98 99
Employee Representation
MGT AFSCME MGT
AFSCME
MGT AFSCME AFSCME OA
30 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment County Codes ACTIVE/ RETIREE County County Code Name 01 Adams 02 Allegheny 03 Armstrong 04 Beaver 05 Bedford 06 Berks 07 Blair 08 Bradford 09 Bucks 10 Butler 11 Cambria 12 Cameron 13 Carbon 14 Centre 15 Chester 16 Clarion 17 Clearfield 18 Clinton 19 Columbia 20 Crawford 21 Cumberland 22 Dauphin 23 Delaware 24 Elk 25 Erie 26 Fayette 27 Forest 28 Franklin
County Code
County Name 29 Fulton 30 Greene 31 Huntingdon 32 Indiana 33 Jefferson 34 Juniata 35 Lackawanna 36 Lancaster 37 Lawrence 38 Lebanon 39 Lehigh 40 Luzerne 41 Lycoming 42 McKean 43 Mercer 44 Mifflin 45 Monroe 46 Montgomery 47 Montour 48 Northampton 49 Northumberland 50 Perry 51 Philadelphia 52 Pike 53 Potter 54 Schuylkill 55 Snyder 56 Somerset
31 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment County Codes ACTIVE/ RETIREE Continued County County Code Name
County Code
County Name
57 Sullivan 58 Susquehanna 59 Tioga 60 Union 61 Venango 62 Warren 63 Washington 64 Wayne 65 Westmoreland 66 Wyoming 67 York 88 Out of State – Basic Coverage 99 Out of Country
32 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
ACTIVE Group Codes Groups
Subgroups
COBRA Subgroups
Medical Options
840EAW Hired on or after 8/1/03
SBO
TMP
WRD
COB
C11
C35
CSD
Supplemental Benefits Only
C,H,M,O,P,R,V
940EAW
SBO
TMP
WRD
COB
C11
C35
CSD
Supplemental Benefits Only
C,H,M,O,P,R,V
840III Hired on or after 8/1/03
TMP
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
940III
TMP
WRD
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
840STL
OFT
OPT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940STL
OFT
OPT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840ODD
BIL
NON
Basic, CDHP, HMO, PPO, MHMO, MPFFS, MPPO
C,H,M,O,P,R,V
940ODD
BIL
NON
Basic, CDHP, HMO, PPO, MHMO, MPFFS, MPPO
C,H,M,O,P,R,V
840TSS Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
940TSS
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
840WDG Hired on or after 8/1/03
OFT
OPT
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
940WDG
OFT
OPT
COB
C11
C35
CSD
CDHP, HMO, PPO
C,H,M,O,P,R,V
WRD
WRD WRD
33 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
ACTIVE Group Codes Continued Groups
Subgroups
COBRA Subgroups
Medical Options
Rider Codes
8400IC Hired on or after 8/1/03
TMP
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
9400IC
TMP
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
8400US Hired on or after 8/1/03
SBO
COB
C11
C35
CSD
N/A
C,H,M,O,P,R,V
9400US
SBO
COB
C11
C35
CSD
N/A
C,H,M,O,P,R,V
802000 Hired on or after 8/1/03
OFT
INT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
902000
OFT
INT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
826000 Hired on or after 8/1/03
OFT
COB
C11
C35
CSD
PPO
N/A
926000
OFT
COB
C11
C35
CSD
PPO
N/A
831000 Hired on or after 8/1/03
SNL
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
931000
SNL
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
832000 Hired on or after 8/1/03
OFT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
932000
OFT
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
34 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
ACTIVE Group Codes Continued Groups
Subgroups
COBRA Subgroups
Medical Options
Rider Codes
840000 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940000
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840002 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940002
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840003 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940003
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840039 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940039
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840090 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940090
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
35 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
ACTIVE Group Codes Continued Groups
Subgroups
COBRA Subgroups
Medical Options
Rider Codes
840098 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
940098
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
840076 Hired on or after 8/1/03
OFT
OPT
WRD
COB
C11
C35
CSD
CDHP,HMO,PPO
C,H,M,O,P,R,V
36 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Active PSP Group Codes Groups
024937
Subgroups
OFT
COBRA Subgroups COB
C11
C35
Medical Options
CSD
Basic, PPO
Rider Codes Y, Z
37 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Retired Group Codes SubGroups
919005 Fully State Paid Retiree
FSP-Fully State Paid
WRD –Work Related Death
SSB
SSF
SSP
COBRA Subgroups COB C11
919705 Fully State Paid Retiree after 7/1/04
FSP-Fully State Paid
WRD –Work Related Death
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP, MPPO, MHMO, MPFFS
B, O, S, 1
919505 Retired after 7/1/05
NPY- FSP not paying the 1%
PAY – Retiree paying 1%
WRD –Work Related Death
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP, MPPO, MHMO, MPFFS
B, S, O, 1
919305 Retired after 7/1/07
NPY –FSP not paying the 1%- %
PAY – Retiree paying the 1%-3%
WRD – Work Related Death
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP, MPPO, MHMO, MPFFS
B, S, O, 1
919033 Non FSP Retiree
005-NSPF Retiree $5.00 SHR
010 – NFSP Retiree $10. SHR
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, MPPO, MHMO, MPFFS
B, G, J, K, N, O, S, 1
919733 Non FSP Retiree after 7/1/04
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP MPPO, MHMO, MPFFS
B, G, J, O S, 1
919533 Non FSP Retiree after 7/1/05
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP MPPO, MHMO, MPFFS
B, G, J, S, 1
919333 Non FSP Retiree after 7/1/07
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP,MPPO MHMO, MPFFS
B, G, J, S, 1
Groups
NPY – RSP not paying the 1%
SSA Subgroups
Medical Options Basic, PPO, HMO, MPPO, MHMO, MPFFS
Rider Codes B, O, S, 1
38 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Retired Group Codes Continued Groups
Subgroups
010 – NFSP Retiree $10. SHR
SSA/Subgroups
COBRA Subgroups
Medical Options
Rider Codes
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO,MPPO, MHMO, MPFFS
B, G, J, K, N, O, S, 1
919053 Non FSP Retiree
005-NSPF Retiree $5.00 SHR
919753 Non FSP Retiree after 7/1/04
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP,MPPO, MPPO, MHMO, MPFFS
B, G, J, O S, 1
919553 Non FSP Retiree after 7/1/05
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO,HMO,CDHP,MPPO, MHMO,MPFFS
B,G,J,O, S,1
919353 Non FSP Retiree after 7/1/07
005-NSPF Retiree $5.00 SHR
SSB
SSF
SSP
COB
C11
Basic, PPO,HMO,CDHP,MPPO, MHMO,MPFFS
B, G, J, S, 1
919ODD PEBTF ODD GROUP
BIL-Mixed REHP and Active Supp
Basic, CDHP, HMO, PPO, MHMO, MPFFS, MPPO
C, D, H, O, R, V
NON-Mixed Benefits REHP and active supp
39 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Retired TIACREF Group Codes TIACREF Group
Retiree/Subgroups
SSA/Subgroups
COBRA Subgroups
Medical Options
Rider Codes
919010 FSP Retiree
FSP Fully State paid
NFP – 100% billed with $5.00 state share only
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, MPPO, MHMO, MPFFS
B, O, S, 1
919710 FSP Retiree after 7/1/04
FSP Fully State paid
NFP – 100% billed with $5.00 state share only
SSB
SSF
SSP
COB
C11
Basic, PPO, HMO, CDHP, MPPO, MPPO, MHMO, MPFFS
B, O, S, 1
919510 FSP Retiree after 7/1/05
NFP 100% billed with $5.00 state share only
NPY Fully State Paid Retiree Not paying the 1%
PAY Retiree Paying the 1%
SSB
SSF
SSP
COB
C11
Basic, PPO,HMO,CDHP, MPPO, MHMO, MPFFS
B,O,S,1
919310 FSP Retiree after 7/1/07
NFP 100% billed with $5.00 state share only
NPY Fully State Paid Retiree Not paying the 1%
PAY Retiree Paying the 1%
SSB
SSF
SSP
COB
C11
Basic, PPO,HMO,CDHP, MPPO, MHMO, MPFFS
B, S, 1
40 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Retired State Police Group Codes Group
Retiree/ Subgroups
SSA/Subgroups
COBRA Subgroups
Medical Options
Rider Codes
919012 Retired Pre – 7/1/04
FSP
SSF
SSP
SSB
COB
C11
Basic, PPO
F, T
919013 Retired Pre – 7/1/04
FSP
SSF
SSP
SSB
COB
C11
Basic, PPO
F, O, T
919015
FSP
SSF
SSP
SSB
COB
C11
Basic, PPO
F,L
919014 Retired Pre – 7/1/04
FSP
SSF
SSP
SSB
COB
C11
Basic, PPO
F, O, T
919795 Retired Pre – 7/1/04
FSP
SSF
SSP
SSB
COB
C11
919704 Retired Post – 7/1/04
FSP
SSF
SSP
SSB
COB
C11
Basic, PPO
F, O, U, X
919405 Retired on or after 4/21/05
FSP
SSF
SSP
SSB
COB
C11
919707 Retired on or after 7/1/07
FSP
SSF
SSP
SSB
COB
C11
A, F, O
Basic, PPO
F, L, O, 1
41 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Rider Codes PEBTF Rider Codes A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 1 2 3 4 5 6 7
Prescription Drug – 919405 PSP Retirees 610 Prescription Drug Non-PSP Non-Medicare Eligible Retirees United Concordia’s Dental PPO Delta Dental PSP Dental – 919006 – Informational only, do not transmit eligibility PSP Dental – 919009, 919012, 919013, 919014, 919795, 919405 REHP RX Coverage Only - $5.00 Share – Medicare Eligible Hearing Aid COBRA – REHP RX Coverage Only – Medicare Eligible REHP RX Coverage Only - $5.00 Share – Non-Medicare Eligible REHP RX Coverage Only - $10.00 Share – Medicare Eligible PSP Prescription Drug for those retired on or after 7/1/07 Mail Order Only/Restricted to one Pharmacy REHP RX Coverage Only - $10.00 Share – Non-Medicare Eligible Opt Out of Disease Management Program Concordia Plus (United Concordia) COBRA 11 month Extension – REHP RX Coverage Only – Medicare Eligible 013 – Prescription Drug – Actives 610 – Prescription Drug – Non-PSP Medicare Eligible Retirees 575 – Prescription Drug – PSP Retirees 071 – Prescription Drug – 919795 PSP Retirees Vision COBRA 11 month Extension – REHP RX Coverage Only – Non-Medicare Eligible 071 – Prescription Drug – 919795 PSP Survivor Spouse Active PSP-COBRA HRA Active PSP Troopers – Supplemental Benefits PEBTF tertiary COBRA REHP RX Coverage Only – Non-Medicare Eligible Medicare Part D Plan Medicare Part D Plan Medicare Part D Plan Medicare Part D Plan Medicare Part D Plan 42
Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Dependent Status Codes (Status codes are for informational purposes only) Status Benefit Eligibility Definition Code Medical Supplemental A AB B BC BL C D DD DQ E ES F FO G H HO HP I J K L M ME MR N NA NB NS
N Y N Y Y N Y N N Y Y N N N N Y Y N N N N N Y N N Y Y Y
N Y Y Y Y N Y N N Y Y N N N Y Y Y N N N N N Y N Y Y Y Y
Qualifying Events
Overage student/student dependents who do not certify/recertify
COBRA HIPAA Survivor Spouse X* X
Not eligible for Medicare A&B exception to MPFFS Dependent eligible for Supplemental Benefits Only Birth Certificate has not been verified Black Lung benefit – exception to MPFFS Plan Covered under another COP contract for PEBTF Medical and Supplemental coverage Disabled Dependent – eligible for all benefits Disabled Dependent – termed March 2013
X
Billable member terminated for delinquency
X X
Eligible/generic - eligible for all benefits Member ESRD Coverage terminated/fraud/abuse case
X
X X X
X X
X X X
X
X
Final opt out REHP benefits No longer financially responsible Disabled Dependent eligible for Supplemental Benefits only nd
Health oversight committee/only use 2 status code field Hospice & in last 6 months of life exception to MPFFS Ineligible/Generic Dependent has other group coverage Dependent is employed full time Deceased Dependent Dependent marries Medicare ext/applied for part B MPFFS exception REHP member opted out of Medical and RX
X
Full-time student dependent eligible for Supplemental Benefits only Not eligible for Medicare Part A exception to MPFFS Not eligible for Medicare Part B exception to MPFFS Member does not have SSN/MED ADV enrollment exception
43 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Status Benefit Eligibility Definition Code Medical Supplemental O OB OC OM OR OS OX P PD PE PO Q R RP RR S SB SD SP T TP U UC UM V W X XX Z
Y Y Y N Y Y N N Y Y N N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y N
Y Y Y Y N Y N N Y Y Y N Y N Y Y Y N Y Y/N N Y Y Y N N N Y Y
Qualifying Events COBRA HIPAA Survivor Spouse
Student that has been called to active military duty (Reserve/National Guard) REHP member opt back into medical or RX coverage Member has other coverage exception to MPFFS REHP member opted out of Medical REHP member opted out of RX coverage Member resides out of state MPFFS exception REHP member opted out of all coverage Divorce
X
X
Member paid delinquent premiums Provider exceptions to MPFFS (out of state only) PEBTF opted REHP member out of Medical Separation
X
Request for student certification Member opt out – other coverage – med remediation project
X
Railroad Retirement exception to MPFFS Certified full-time student – eligible for all benefits Dependent covered under senate bill 189 Dependent previously covered under senate bill 189 Member had RPASP coverage exception to MPFFS Split contract – Child or Spouse REHP Medical Only as exception Dependent turning 19 yrs old / first request for student certification Unique medical condition exception to MPFFS United Mine Workers of America exception to MPFFS Dependent eligible for PEBTF medical coverage only Full-time student dependent – eligible for PEBTF medical coverage only Disabled dependent eligible for PEBTF medical coverage only Member resides out of the country MPFFS exception Dependent covered under another EE’s contract for medical
44 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Current Plan Codes Active Plan Codes Effective Date
Plan Act ID Type Plan Code
PA State Police Troopers Basic Option (Blue Shield & MM) Pennsylvania Blue Shield PA State Police Troopers PPO Option (Hired 04/21/05 or after) PPO Blue
07/01/02
B
378
04/01/05
0
APO
Consumer Driven Health Care Plan United Healthcare
01/01/06
D
056
PPO Option Highmark
01/01/11
O
055
HMO Option Aetna/US Healthcare HMO PA Keystone Health Plan Central Keystone Health Plan West Geisinger Health Plan
07/15/91 10/01/88 10/01/88 10/01/88
H H H H
014 023 037 080
No Medical Coverage Supplemental Benefits Only No PEBTF Coverage Need Dependent Documentation
10/01/88 10/01/88 08/27/07
A N N
000 NOC NDD
45 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Current Annuitant Plan Codes Effective Date
Plan Ann ID Type Plan Code
Basic Option (Blue Cross, Blue Shield & Major Medical) Plan Codes for Individuals Retiring Prior to 07/01/2004 Capital Blue Cross Out of State/Country Capital Blue Cross (Blue Cross & Major Medical)
05/01/02 10/01/88
B B
560 561
07/01/04 07/01/04
B B
760 761
07/01/04 07/01/04
S S
S60 S61
07/01/04 07/01/04
S S
M60 M61
11/15/08 11/15/08
S S
SNB MNB
05/01/02 05/01/02
S S
A60 B60
10/01/88 10/01/88
S S
A61 B61
Plan Codes for Individuals Retiring 07/01/2004 or After Capital Blue Cross Out of state/Country Capital Blue Cross (Blue Cross & Major Medical)
Plan Codes for Individuals with Medicare who are on a Contract with Individuals who are not Medicare Eligible PEBTF Supp to Medicare PEBTF use ONLY PEBTF Supp to Medicare PEBTF use ONLY
Plan Codes for Total Medicare Contract PEBTF Supp to Medicare PEBTF use ONLY PEBTF Supp to Medicare PEBTF use ONLY
Plan Codes for Individuals with Medicare who are in a temporary plan code with the PEBTF PEBTF Split TEMP plan PEBTF pays 100% PEBTF TEMP Supp to Medicare PEBTF pays 100% PEBTF use ONLY
Capital Blue Cross - Out of State/Country Traditional Medicare (Supp to Medicare A & Major Medical) Traditional Medicare (Supp to Medicare B, Basic Blue Cross & Major Medical)
Capital Blue Cross Traditional Medicare (Supp to Medicare A & Major Medical) Traditional Medicare (Supp to Medicare B, Basic Blue Cross & Major Medical)
46 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Current Annuitant Plan Codes Continued Effective Date
Plan Type
Ann ID Plan Code
01/01/03 01/01/03 01/01/03 01/01/03 04/21/05 04/21/05 04/21/05 04/21/05 07/01/11 07/01/11
B B B B O O O O S S
HRP HPA HPB HPC RPO RPA RPB RPC TPA TPB
01/01/11
O
555
01/01/03 01/01/03
O O
A65 B65
01/01/11
O
755
01/01/11
S
S55
01/01/10 01/01/10 01/01/13
X X X
M20 M21 M28
PA Retired State Police (Blue Shield & MM) Highmark Traditional Medicare Part A Only Traditional Medicare Part B Only Traditional Medicare Parts A & B Highmark Blue – PPO Traditional Medicare Part A Only Traditional Medicare Part B Only Traditional Medicare Parts A & B Highmark Signature 65 – retired after 04/01/05 Highmark Signature 65 – retired before 04/01/05
X
X
PPO/POS Option Plan Codes for Individuals Retiring Prior to 07/01/2004 Highmark PPO
Plan Codes for Individuals Retiring Prior to 07/01/04 with only one part of Medicare Traditional Medicare Part A Only Traditional Medicare Part B Only
Plan Codes for Individuals Retiring 07/01/2004 and After Highmark PPO
Plan Codes for Individuals with Medicare who are on a Contract with Individuals who are not Medicare Eligible Highmark PPO
MPPO Option Aetna Aetna (ESA) Aetna (ESA)
47 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Current Annuitant Plan Codes Continued Effective Date
Plan Type
Ann ID Plan Code
01/01/10 01/01/10 01/01/13
X X X
S20 S21 S28
01/01/10 01/01/10 01/01/10 01/01/10 01/01/10 01/01/10
M M M M M M
M22 M23 M24 M25 M26 M27
01/01/10 01/01/10 01/01/10 01/01/10 01/01/10 01/01/10
M M M M M M
S22 S23 S24 S25 S26 S27
02/01/97 02/01/97 02/01/97 02/01/97
H H H H
541 546 549 550
Plan Codes for Individuals with Medicare who are on a Contract with Individuals who are not Medicare Eligible Aetna PPO Aetna ESA Aetna ESA
X
MHMO Option Aetna (in state) Aetna (Out of state) Geisinger (Central) Geisinger (Northeast) UPMC UPMC (Flex)
Plan codes for Individuals with Medicare who are on a contract with individuals who are not Medicare Eligible Aetna (in state) Aetna (Out of state) Geisinger (Central) Geisinger (Northeast) UPMC UPMC (Flex)
Non-Medicare HMO Option Plan Codes for Individuals Retiring Prior to 07/01/2004 Geisinger Health Plan Keystone Health Plan Central Keystone Health Plan West Aetna/US Healthcare HMO PA
48 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Current Annuitant Plan Codes Continued Effective Date
Plan Type
Ann ID Plan Code
07/01/04 07/01/04 07/01/04 07/01/04
H H H H
741 746 749 750
01/01/06 01/01/06
D S
756 M56
05/01/08 05/01/08 05/01/08
R R R
S00 500 M00
07/01/09
N
NBS
Plan Codes for Individuals Retiring 07/01/2004 and After Geisinger Health Plan Keystone Health Plan Central Keystone Health Plan West Aetna/US Healthcare HMO PA
Consumer Driven Health Plan Option CDHP available for members retiring on or after 7/1/04 CDHP available for members retiring on or after 7/1/04 Medicare Eligible
RX Coverage only REHP RX coverage only split contracts REHP RX Coverage only non-Medicare members REHP RX coverage only Medicare eligible
Plan Codes for deceased individuals in order to extend coverage an additional 21 days past the notification date No REHP Benefits
Plans for which we have multiple benefits in house (ex. Major Medical & Med. Supp) may require the use of the field, BRUSD, to vary the adjudication rules within the same plan.
49 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Relationship Codes A Brother/Sister DA Domestic Partner Brother/Sister D Disabled Dependent DD Domestic Partner Disabled Dependent M Student on Approved Medical leave DM Domestic Partner Approved Medical Leave N Newborn added for first 31 days DN Domestic Partner newborn added for first 31 days P Student medical leave pending approval DP Domestic Partner Student medical leave pending approval R Student medical leave denied or ended DR Domestic Partner Student medical leave denied or ended Q Dependent with QMCSO DQ Domestic Partner Dependent with QMCSO 0 Niece/Nephew D0 Domestic Partner Niece/Nephew 1 Employee 2 Spouse D2 Domestic Partner 3 Natural/Adopted Child D3 Domestic Partner Natural/Adopted Child 4 Dependent Parent (RX only) 5 Stepchild D5 Domestic Partner Stepchild 6 Legal Ward D6 Domestic Partner Legal Ward 7 Foster Child D7 Domestic Partner Foster Child 8 Grandchild D8 Domestic Partner Grandchild 9 Cousin D9 Domestic Partner Cousin
50 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Department Codes Commonwealth of Pennsylvania Departments KEY O O O O O O O O O O O O O O O O O O O O O O O O O O **O O O O O O O O O
Dept Code 0099 0002 0003 0068 0075 0066 0067 0078, 7802, 7803 0079 0010 0011 0012, 1202, 1203 0013, 1301 0014 0015 0016, 1601, 1602 0017 0018 0019 0020 0021, 2102, 2103 0022 0023 0024 0025 0026 0027 0028 0029 0030 0031 0032 0033 0034 0035
Translation Governor's Office Auditor General Treasury Agriculture Banking Securities Commission Health Transportation Insurance Aging Corrections Labor & Industry Dept of the Military/Veterans Affairs Attorney General General Services Education Public Utility Commission Revenue State State Police Public Welfare Fish and Boat Commission Game Commission Commerce/Community & Economic Development Probation & Parole Board Liquor Control Board Milk Marketing Board Lieutenant Governor's Office Community Affairs Historical & Museum Commission Emergency Management Agency Civil Service Commission PennVest (PA Infrastructure Investment Authority) PA Public TV Network Environmental Protection
51 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Commonwealth of Pennsylvania Departments Cont KEY O O O O O O O O O O O *O *O *O O *O *O *O O O O O O O O O O O
Dept Code 0036 0037 0038 0039 0040 0043 0065 0070 0071 0072 0074 0081 8101 8102 0084 0088 8801 8802 0090 0091 0092 0098 0994 0995 0996 0997 0998 0999
Translation State Tax Equalization Board Environmental Hearing Board Conservation & Natural Resources PA Higher Education Assistance Agency Ethics Commission PA Health Care Cost Containment Council Gaming Control Board State Employees Retirement Board Municipal Retirement Board PA State Employees Retirement System Drug and Alcohol Programs Executive Offices Human Relations Commission Juv Crt Jdgs Comm Ship Univ PA E-Health Partnership Authority PA Port Authority Philadelphia Reg Port Auth Port of Pittsburgh Commission State System Higher Education Annuitants PSERS State Public School Bldg Authority Wood Dining ISSU Staff PNA Staff PSSU Staff AFSCME Staff PEBTF Staff
NOTE: Not all departments are covered by the PEBTF O = PEBTF LIST * = LISTED 2 TIMES OR 2 DIFFERENT DEPTS ** = MERGED WITH ANOTHER DEPARTMENT (081)
52 Revised 12/13/2012 – MC4-TP
PEBTF 834 5010 Outgoing Eligibility
Attachment Subscriber/Dependent Suffix Values ESQ Esquire I First II Second III Third IV Fourth JR Junior MD Medical Doctor SR Senior V Fifth VI Sixth
53 Revised 12/13/2012 – MC4-TP
