- UNET - HIPAA 834 5010 available for large group
- Spectera - HIPAA 834 5010 for vision only clients
- Gateway Standard Format - Not supported
Carrier Implementation Timeline: 10-15 weeks
Carrier Documentation :
UHC's will send you a Electionic Eligibility Management System (EEMS) document. There are 3 important embedded documents:
- Electronic Eligibility Questionnaire - to be completed by the licensee and returned to UHC and a copy to EN
- UHG HIPAA 834 5010 Companion Guide
- Test Scenarios
Configuring Self-Service 834 5010:
Type = 834 5010
Carrier = UnitedHealthcare
Source Platform = UnitedHealthcare - UNET
Export Name = Select the name of your choosing
Exclude COBRA = Select when UHC is administering COBRA for the group.
Include Open Enrollments? = Select when reporting on open enrollment elections, before open enrollment has been closed out.
Select the check box next to each plan to include in the file. Select the appropriate Insurance Line Code (HD03) for each plan. Refer to the Companion Guide for HD03 codes.
UnitedHealthcare bundles the medical and prescription benefit into one plan, but requires a separate records to be transmitted on the file. If carrier provides an HD03 code for a prescription plan that is not listed under the Plans tab, you will need to configure plan bundles. Use the Plan Bundles to assign the HD03 code for the Prescription plan to each medical plan.
To complete this, navigate to the UHC File >> under Plan Options (left navigation panel), click on Plan Bundles >> click "add" link and from the drop-down select the code to be "bundled" - in this instance it would be PDG. Don't forget to click save.
Refer to the Companion Guide and Group Structure for more complete details on configuring the loops and segments in the 834.
- ISA06 = Customer or TPA Federal Tax ID
- GS02 = TPA or Customer Name (Up to 15 characters)
- GS06 = Group control number assigned by customer and/or TPA must match GE02 in footer
- BGN02 = TPA name or customer name, up to 30 characters
- REF02 = Group ID #. Provided by UHC. Alpha only, minimum of 4 characters maximum of 8 characters and should be all caps.
- N102 = Full TPA or Customer name of the Federal Tax ID sent in the 1000A Loop N104, may be up to 60 characters
- N104 = Federal Tax ID of the TPA or Customer Named in N102
- REF1L =Numeric 7 digit UHC Customer. Configure on both the Employee and Dependent Tab
Situational REF and DTP Segments: UHC offers many situational segments. Refer to the group structure and exclude any situational segments not requested by the carrier. Important Note! UHC suggestions excluding the DTP356 (Eligibility Begins) and DTP357 (Eligibility Ends) as they may affect how the coverage effective date is loaded into their system.
Loop 2100A: Situational Segments: ICM, AMT, HLH, and LUI are situational segments and should be excluded unless your plans require it and carrier requests.
Loop 2100C: Situational Loop: Exclude, unless carrier requests.
- HD03- Set at the Plans tab. See above for more information.
- HD04- UHC Provided Plan Codes
- Plan Variation Code: Positions 1-4 (EX: 0001)
- Report Code: Positions 5-8 (EX: 0001)
- Plan Type: Positions 9-10 (EX: TT= Medical, V= Vision, and D= Dental) For those with only 1 Character left justify with a space.
- Cobra Indicator: Positions 11-12 (EX TY for Cobra if no Cobra not required)
- Executive Medical: Positions 13-15 (Only use if applicable, file Analyst will advise)
- Active Example Medical: 00010001TT Cobra Example Medical: 00010001TTTY
Situational REF and AMT Segments: UHC offers many situational segments. Refer to the group structure and exclude any situational segments not requested by the carrier.
Required for HMO plans that require PCP only- turn off at client level if not required
- Exclude all except: LX & NM1
Additional Situational Loops not currently supported by Employee Navigator. Please contact us if you need to implement a file with these loops.
- 2330: Coordination of Benefits Related Entity
- 2750: Reporting Category Reference
- GE02: Must be same value as GS06 assigned by TPA or client
Additional Carrier Notes:
- Terminated records are set to drop from this carrier’s file feeds at 14 days past the termination date.
- PGP Key is stored on the carrier configuration
- QMSCO: UHC requires a separate relationship code of "Ward and a relationship value of 15" to be passed along with the address requirements and EN does not support this. You have 2 options for this scenario:
- If they require the separate relationship code, manually inform UHC when there is a court order and the QMSCO's address needs to be updated.
- Get an approved exception for UHC to continue to accept the standard dependent relationship code (19) and the dependent address listed as the address of the custodial parent it can be supported
UHC Electronic Eligibility Questionnaire
- UHC requires that an Electronic Eligibility Questionnaire be completed for each client.
- This document is embedded on page 5 of the Companion Guide
- If you use UHC extensively, Employee Navigator recommends you complete the non-company specific questions and save on an internal drive so you can update as necessary; this should expedite this step for you.
- FAQs re: the Questionnaire:
- QMSCO: The answer is option 3. Unless they create an exception, you will need to manually inform UHC when there is a court order and the QMSCO's address needs to be updated.
UHC Error Reporting
- When UHC processes the weekly eligibility file, they will return a discrepancy (or error) report that must be reviewed in a timely manner. UHC posts ALL error reports in their Employer eServices portal. They will notify you via a secure email with a link to the eServices portal.
- The eServices portal offers multiple tutorials that can be viewed on-demand, including Enrollment, Invoices (Billing), Reporting, And Electronic Eligibility Management System Tutorials. The last is the most important if you are sending 834 files. If you have additional questions about the reports, please direct those to your UHC Electronic Eligibility Analyst.
- UHC prefers that the open enrollment file included ended and open enrollments.
- All eligibility maintenance files for the current plan year should cease after the open enrollment file has been sent. Files should resume after the new benefit year.
- UHC does NOT require a different naming convention for the open enrollment file.
- The clients assigned UHC Eligibility Analyst should be notified the day prior to the Open Enrollment file being sent.
- UHC request that the Open Enrollment questionnaire (attached 2015 Open Enrollment Questionnaire) be completed. Please note, questions 15 and 16 should be filled out for groups that are going through structure changes. Question 16 for a group that has no changes.
Note: Any excel templates attached to this article are intended to be used for only those clients who are in the process of implementing an EDI file and testing has not been completed prior to the Open Enrollment file needing to be sent.
last updated 1/15/2015