We are a 3rd party administrator for health & COBRA benefits. We require a termination reason. The INS*07 could communicate if COBRA benefits apply and how much coverage should be offered. We’d like to load the termination reason electronically.EDI providers send the INS*05 = C stating our request is non-HIPAA compliant. When the person terminates coverage – their status (INS*05) is still A. If the person actually enrolls in COBRA benefits – the INS*05 would be C. I have read the 834 standard (ASC X12N/005010X220) and do not see where this should be considered invalid. We process full files, so we ask for an XN in the INS*04. Our clients have to send termination reasons separately and our staff enters it manually which is duplicate work. I contacted EDIFECS and a few EDI providers and they do not want to make changes, unless they see it in the guide. The only thing I could see is the standard comment of - If not required by this implementation guide, do not send. Thanks!
INS04=XN can only be used when INS03=030, i.e. an Audit or Compare file. Section 1.4.5 clarifies that full audit files are intended to identify active members and may include terminated members as well but the full audit file is not intended to make changes to the enrollment database. Full files in which changes are intended to be made to an enrollment database are identified by (BGN08=RX “Replace”.
INS05 identifies the type of coverage under which an enrollee’s benefits are paid, it is not used to identify the type of coverage an enrollee is eligible for.
If the member is enrolling in COBRA or is enrolled in COBRA, INS05=C, then INS07 is used to convey the qualifying event that enabled the member to enroll in COBRA.
The TR3 does not support identifying potential COBRA benefits, it only supports enrolling someone in COBRA or identifying that they are enrolled in CORBA. When the termination from non-COBRA enrollment is sent, INS04 is used to identify the reason for the change in enrollment.
A request to add capabilities for new business need(s) to a future version of a Benefit Enrollment and Maintenance (834) TR3 may be submitted to ASC X12 at http://changerequest.x12.org/ .
Original Draft for reference
INS04=XN can only be used when INS03=030, i.e. an Audit or Compare file. Section 1.4.5 clarifies that full audit files are intended to identify active members and may include terminated members as well but the full audit file is not intended to make changes to the enrollment database.
INS05 identifies the type of coverage under which an enrollee’s benefits are paid, it is not used to identify the type of coverage an enrollee is eligible for.
If the member is enrolling in COBRA or is enrolled in COBRA, INS05=C, then INS07 is used to convey the qualifying event that enabled the member to enroll in COBRA.