Below are the loops, segments and elements that may need configured to support the AETNA requirements. Each Loop is identified in a separate section below, and the segment and element are combined into one value.
Example, ISA is the Interchange Control Header Segment and it contains 16 elements. ISA06 is the 6th element within the ISA segment.
- ISA05 = '30' if ISA06 is Federal Tax ID; 'ZZ' if ISA06 is other type of ID
- ISA06 = Identification code published by the sender, the sender always codes this value
- GS02 = Identification code published by the sender, the sender always codes this value
- GS03 = Identification code published by the receiver
- GS06 = Group Control Number assigned by the sender - recommend broker Federal Tax ID
- REF02 = Customer Number (7 bytes) + HMO company code (2 bytes) + 6 digit group number (with leading 0). If no customer number, prefill will 7 blank spaces. Example: 0123456+US+0123456
1000A Loop: Plan Sponsor Name
- N101 = 'P5'
- N102 = Plan Sponsor/Company Name
- N103 = 'FI'
- N104 = Plan Sponsor/Company Federal Tax ID
1000C Loop: TPA/Broker Name
- N101 = 'BO' if broker, 'TV' if TPA
- N102 = Broker or TPA Name
- N103 = 'FI'
- N104 = Broker or TPA Federal Tax ID
2000 Loop: Member Level Detail
Carrier has many optional REF and DTP segments that may be used for transmitting additional date elements, based on plan design.
For simplicity, we recommend excluding all DTP segments, except the DTP_336 and DTP_337, unless carrier indicates otherwise. Many of the optional REF segments and the specific carrier use cases as listed below. if carrier doesn't indicate they need any of the following segments, they can be excluded from the file.
- REF_17: Client Reporting Category (Situational)
- REF01 = '17'
- REF02 = Provided by carrier if further classification is required by contract
- REF_1L: Group or Policy Number (Situational)
- REF01 = '1L'
- REF02 = Group Number provided on group structure
- REF_23: Client Number (Situational)
- REF01 = '23'
- REF02 = Situational to pass payer specific information
- REF_3H: Case Number (Situational)
- REF01 = '3H'
- REF02 = Case Number
- REF_4A: Personal Identification Number (PIN) (Situational)
- REF01 = '4A'
- REF02 = Situational code to transmit a password associated with a member record
- REF_6O: Cross Reference Number(Situational)
- REF01 = '6O'
- REF02 = Situational code t when further classification is required for reporting
- REF_ABB: Personal ID Number (Situational)
- REF01 = 'ABB'
- REF02 = Situational personal ID number
- REF_D3: National Council for Prescriptions Drug Programs Pharmacy Number (Situational)
- REF01 = 'D3'
- REF02 = Pharmacy Number
- REF_DX: Department/Agency Number(Situational)
- REF01 = 'DX'
- REF02 = Use when members in a coverage group are set up as different divisions or departments in contract
- REF_F6: Health Insurance Claim (HIC) Number (Situational)
- REF01 = 'F6'
- REF02 = Required to enroll members in a Medicare Plan
- REF_P5: Position Code (Situational)
- REF01 = 'P5'
- REF02 = Use this code to transmit the title of the member's employment position
- REF_Q4: Prior Identification Number (Situational)
- REF01 = 'Q4'
- REF02 = Use this code to pass the Identifier Number under which the member had previous coverage with the payer.
- REF_QQ: Unit Number (Situational)
- REF01 = 'QQ'
- REF02 = Use this code when members in a coverage group are set to different units under the insurance policy.
- REF_ZZ: Mutually Defined(Situational)
- REF01 = 'ZZ'
- REF02 = Use this code to transmit the title of the member's employment position.
2100ALoop: Member Name
Data in this loop has mostly been configured automatically to pull member demographic information. There are additional segments, which may not be needed based on the contracted plans. These can be excluded if not required by the carrier.
- ICM: Member Income - to supply information to determine eligibility, deductibles, and retirement and investment income
- AMT: Member Policy Amounts - to indicate a monetary amount such as family specific co-insurance, deductible, and premium amounts.
- LUI: Member Language - to specify member language, type of usage, and proficiency or fluency.
2100C Loop: Member Mailing Address
Situational loop, can be excluded since member address is sent in the 2100A Loop.
2200 Loop: Disability Information
Situational loop, and can be excluded if carrier does not require additional disability information. Most carrier do not need this information since they read the Disability indicator in the 2000 Loop, INS10. if additional information needs to be captured and transmitted to the carrier regarding disability, the information would need to be added to this loop.
2300 Loop: Health Coverage
Carrier will provide specific HD04 requirements based on plan design, which is most time consuming component to this carrier configuration. There are many other option REF and DTP segments which can be excluded if nor required for the specific plan design.
- HD04: For HMO plans use - values will be provided by the carrier and will fit this model
- Company Code (2 bytes)+Group number (7 bytes, 6 digit group number with a leading zero)+Class code (5 bytes, 3 digit class code with 2 leading zeros)+Product (5 bytes)+File Number(3 bytes). Example: US+0123456+00001+CITIZ+001
- HD04: For Non-HMO plans - values will be provided by the carrier and will fit this model
- ELR Number (3 bytes)+Control Number (7 bytes)+Suffix (3 bytes)+Account (5 bytes)+Plan (5 bytes, 3 digit plan with 2 trailing zeros)+Claim Office (3 bytes)+Network (5 bytes) Example. 001+1234567+010+00001+00100+164+00011
- REF: Additional optional REF segments. Exclude if not indicated as required by carrier
- REF_17: Client Reporting Category
- REF_1L: Group or Policy Number
- REF_9V: Payment Category
- REF_CE: Class of Contract Code
- REF_E8: Service Contract Nubmer
- REF_M7: Medical Assistance Category
- REF_PID: Program Identification Number
- REF_QQ: Unit Number
- REF_RB: Rate Code Number
- REF_X9: Internal Control Number
- REF_XM: Issuer Number
- REF_XX1: Special Program Number
- REF_XX2: Service Area Code
- REF_ZX: Country Code
- REF_ZZ: Mutually Defined
- DTP: Member Level Dates
- DTP_300: Signature Date - exclude if not required
- DTP_303: Maintenance Effective Date - exclude, carrier will read the 348
- DTP_343: Premium Paid To Date - exclude if not required
- DTP_348: Benefit Begins - Required
- DTP_349: Benefit Ends - Required
- DTP_543: Last Premium Paid Date - exclude if not required
- DTP_695: Previous Ends Date - exclude if not required
- AMT: Health Coverage Policy - typically not required, exclude.
- AMT_B9: Co-insurance - exclude if not required
- AMT_C1: Co-payment - exclude if not required
- AMT_D2: Deductible - exclude if not required
- AMT_P3: Premium Amount - exclude if not required
- AMT_R: Spend down - exclude if not required
- GE02 = Group Control Number (same value as GS06 in Header)
- Open Enrollment files should include NEW enrollments only.
- The file naming convention should remain the same
- When sending the open enrollment file the clients assigned Aetna Management team representative should be notified
Carrier Operational Notes:
- Employee Navigator's EDI engine does not support Aetna's CEF file format. This is a proprietary format that generates and transmits data associated with Health Savings Accounts to the banking partner.