834 Eligibility Enrollment

834 Eligibility Enrollment and Maintenance FAQs (Summa Care)

834 Eligibility Enrollment and Maintenance files, sent to Summa Care, will potentially be checked for HIPAA compliance. Vendors should validate that the file being submitted is HIPAA-compliant prior to submitting the file for testing or production. Find some frequently asked questions below.

  • Can a group be terminated by using the 834?
    The 834 does not provide for termination of a group.
  • What if a contract holder/member does not have a social security number?
    If a member is not a citizen and does not have a social security number, then the social security
    number should be sent in the file as 000000000. If a member is choosing not to provide their
    social security number and they have submitted to us a signed documents stating that neither
    they nor anyone in their family has Medicare, then the social security number should be sent in
    the file as 0000000009.
  • If a full Eligibility load was received and the new group has 1 contract holder/member that has to fulfill the waiting period, the member cannot have the same effective date as the group effective date. Is this possible?
  • When will we get the National Health Number?
    This has not been determined by the government.
  • Can we send advance terminations?
    Yes, a contract holder/member can be terminated 60 days in advance.
  • Do you require a primary care physician (PCP) on new member transmittals?
    Yes, A PCP is required for all lines of business except PPO. SummaCare will however accept PCP’s in the file for PPO members when transmitted. If an invalid PCP number is chosen, the member will appear on an error report and SummaCare will assign a default PCP to that member. A letter of
    explanation will be sent to the member requesting them to choose PCP.
  • Can a member choose an OB (obstetrician) in place of her PCP?
  • How do we code a gender change for a member?
    It would be submitted as a change.
  • How will COB (coordination of benefits) be handled?
    If COB status is unknown for the dependent/spouse, SummaCare will generate a COB
    questionnaire that will be mailed to the member to determine other coverage. All contract holders
    are processed as SummaCare being their primary insurance carrier.
  • What is the time limit for retro-terminating an employee/member?
    90 days.
  • What if a member has coverage under 2 current files with SummaCare?

This circumstance will generate an error report for further investigation. If an employee has two active coverages with SummaCare, a second SummaCare contract number will be created.

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