Text Numeric - Covered California

1 Covered CaliforniaCertification Application for Plan Year 2019 Appendix P ccsb Group XML Schema Element - Transfers employer group information to the issuers system11Y FileInformationContains the elements required to identify the group file MessageIDRandomly assigned Message Id # for XML file Text250Y FileNameName of XML File sentText3939N EnrollmentActionGroup's enrollment action typeCodeY SenderIDPinnacle Tax id assigned as the Sender's Exchange ReceiverIDIssuer's 5 digit assigned by the Employer This element is used to collect the required information about the employer/group1NY NameName of the Employer (Group) Text160Y EmployerIDUnique Identification number for the employerText415Y EmployerTypeCodeClassification of Business Type that the Employer involved in (like Corporation, Church, Tax-Emempt, Partnership etc.,) CodeY TaxPayerIdentificationNumberEmployer Federal Tax Payer Identification Number Numeric99Y GroupSizeNumber of employees qualified to receive healthcare benefit Numeric16N GroupTerminationGroup's Termination Information N GroupTerminationDateTermination date for the groupDateN GroupTerminationReasonCodeReason code value as to why Group is being terminatedText911N OriginalEffectiveDateOriginal enrollment date of the Employer DateY RenewalEffectiveDateEmployer's next annual renewal dateDateN OutOfStateIndicatorOptional indicator of whether the employer group is out of stateIndicator11N AddressThis Segment contains the member employer's address11Y Addressline1 Address line 1 of addressText155Y Addressline2 Address line 2 of addressText155N CityNameCity name of addressText230Y StateCodeState Code for the

2 PostalCodeThe postal zip code of EmployerContactInformationTo provide the communication information for the Employer12Y ContactTypePurpose for which the contact person is being contacted (See values)CodeY ContactPersonNameTo provide the name of the Contact person11Y LastNameLast name of the Contact FirstNameFirst name of the Contact PrimaryTelephoneNumberPrimary Telephone NumberNumeric1010Y PrimaryTelephoneExtensionNumberPrimary Telephone Extension NumberNumeric44N AlternateTelephoneNumberAlternate Telephone NumberNumeric1010N EmailIDElectronic MailText1256Y FaxNumberFax NumberNumeric1010N PreferredContactModePreferred method of communication for Employer CodeY ContinuationCoverageTypeType of Continuation coverage ProvidedCodeN ProbationaryPeriodReports the Probationary Period for the employeeNumeric13N BrokerThis element is used to collect the required information about the Broker01N NameName of the BrokerText160N TaxPayerIdentificationNumberFederal Tax Payer Identification NumberNumeric99N

3 AccountNumberAccount number assigned by the state to the BrokerText135N BrokerContactInformationTo provide the communication information for the Broker01N ContactPersonNameTo provide the name of the Contact person for Broker01N LastNameLast name of the Contact FirstNameFirst name of the Contact PrimaryTelephoneNumberPrimary Telephone NumberNumeric1010N PrimaryTelephoneExtensionNumberPrimary Telephone Extension NumberNumeric44N AlternateTelephoneNumberAlternate Telephone NumberNumeric1010N EmailIDElectronic MailText1256N FaxNumberFax NumberNumeric1010N PreferredContactModePreferred method of communication for BrokersCodeNPlansThis element is used to collect the required information about the employer Plans11Y PlanIndividual Plan related information is collected in this element1NY PlanIDPlan ID that the employer is offering.

4 This plan ID will be used by the carrier to setup a Group ID for any employees enrolling in the PlanStartDatePlan start date - effective date of the MetalLevelCodeType of Metal Level: Medical: Bronze, Silver, Gold, or Platinum; and Dental: CHD or Family (or FAM) and (High & Low til 12/2015)Code11Y CoverageTypeIndicates the type of coverage for the Plan (see value)CodeNAdditionalNotesCaptures any other additional Information for the employer group125601N1 XSD Element NameIs Mandatory ?PurposeMin LengthMax LengthMinOccMaxOccCovered CaliforniaCertification Application for Plan Year 2019 Appendix P ccsb Group XML Schema EnrollmentFor enrolling a new Group MaintenanceFor changes made to the Group information Terminate For whenever Group is to be Terminated RenewalUsed whenever the Group Renews for another yearReinstateUsed whenever the Group is Reinstated after being terminated ContactTypeBilling Contact Information for Billing related communicationBenefits Contact Information for Benefits related communicationBoth Contact Information for Both Billing & Benefits related communicationPreferredContactModeMail Contact through postal mail Email Contact through electronic mailCoverageTypeEMP Employee only Plan FAM Employee + Family PlanMetalLevelCodeBronzeBronze Health PlansSilverSilver Health PlansGoldGold Health PlansPlatinumPlatinum Health PlansFamily or FAMF amily Dental CHDP ediatric Only Dental HighHigh for Groups that are

5 Still on 2014 Plans and have not renewed yet!LowLow for Groups that are still on 2014 Plans and have not renewed yet!ContinuationCoverageTypeCContinuatio n Coverage provided through COBRA SState Mandated Continuation CoverageOutOfStateIndicatorN No YYesEmployerTypeCodeC-CorpPrivate Sector - Corporation Type C S-CorpPrivate Sector - Corporation Type SSelf-EmployedPrivate Sector - 1040 Schedule C Business (self-employed)PartnershipPrivate Sector - Partnership EntityTaxExempt-OrganizationPrivate Sector Tax Exempt organization including corporation, trust, limited liability company, or associationChurchChurch or Church-affiliatedLocalGovernmentState or Local GovernmentForeignGovernmentForeign GovernmentSole ProprietorshipSole ProprietorshipFileName<xml filename>Name of XML file sent out: 2015_08_15_xxxxx_GRP_<date-time>.xml which should be used to extract and send back to Exchange immediately within 24 hrs. GroupTerminationReasonCodeTo Provide a highlevel reason for Group by the Employer to terminateInVoluntaryTerminated for other reason such as Non-Payment!

6 XSD Node NameQualifierExplanationCovered CaliforniaCertification Application for Plan Year 2019 Appendix P ccsb Group XML Schema Hanson9/29/2014 Added the following new fields: i) Group Size; ii) Group Termination Date; iii) Plan Start Date;. Moved Metal Level down to Plan level section. For Open Enrollment Action - added 1 new Code value: "Renewal". Hanson6/17/2015 Added the following lines: 1. Added "Reinstate" code under EnrollmentAction; 2. Added xml Filename; 3. Added new GroupTermination sub-hdr line and a GroupTerminationReasonCode field; 4. Added 2 Qualifier Values for Hanson8/15/2015 Amendment: Removed FileConfirmationCode and FileResponseCode values; Hanson9/30/2015 Made some minor word corrections and additions to this sheet Hanson10/9/2015 Amended Metal level value as both FAM and Family as it could be either but translat to family plan.