X12 834 Benefit Enrollment and Maintenance (X220A1)
This X12 Transaction Set contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA).
For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency.
The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups.
For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- BE
- Benefit Enrollment and Maintenance (834)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X220A1
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 834
- Benefit Enrollment and Maintenance
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X220A1
Beginning Segment
To indicate the beginning of a transaction set
Code identifying purpose of transaction set
- 00
- Original
If the original transaction has already been processed, an incoming transaction using this code may be rejected by the receiver. The rejection will be identified to the sender by telephone or other direct contact.
The "00" indicates the first time the transaction is sent.
- 15
- Re-Submission
Send the "15" when the original transmission was incorrect, has yet to be processed by the receiver, and a new corrected transmission is being sent. This transmission can then be pended by the receiver's translator for further review.
- 22
- Information Copy
Send the "22" when the original transmission was lost or not processed, and the sender is passing another transmission that is the same as the original.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BGN02 is the transaction set reference number.
- This element is the transaction set reference number assigned by the sender's application. It uniquely identifies this occurrence of the transaction for future reference.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BGN03 is the transaction set date.
- This element identifies the date that the submitter created the file.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BGN04 is the transaction set time.
- This element is used as a time stamp to uniquely identify the transmission.
Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow
- BGN05 is the transaction set time qualifier.
- 01
- Equivalent to ISO P01
- 02
- Equivalent to ISO P02
- 03
- Equivalent to ISO P03
- 04
- Equivalent to ISO P04
- 05
- Equivalent to ISO P05
- 06
- Equivalent to ISO P06
- 07
- Equivalent to ISO P07
- 08
- Equivalent to ISO P08
- 09
- Equivalent to ISO P09
- 10
- Equivalent to ISO P10
- 11
- Equivalent to ISO P11
- 12
- Equivalent to ISO P12
- 13
- Equivalent to ISO M12
- 14
- Equivalent to ISO M11
- 15
- Equivalent to ISO M10
- 16
- Equivalent to ISO M09
- 17
- Equivalent to ISO M08
- 18
- Equivalent to ISO M07
- 19
- Equivalent to ISO M06
- 20
- Equivalent to ISO M05
- 21
- Equivalent to ISO M04
- 22
- Equivalent to ISO M03
- 23
- Equivalent to ISO M02
- 24
- Equivalent to ISO M01
- AD
- Alaska Daylight Time
- AS
- Alaska Standard Time
- AT
- Alaska Time
- CD
- Central Daylight Time
- CS
- Central Standard Time
- CT
- Central Time
- ED
- Eastern Daylight Time
- ES
- Eastern Standard Time
- ET
- Eastern Time
- GM
- Greenwich Mean Time
- HD
- Hawaii-Aleutian Daylight Time
- HS
- Hawaii-Aleutian Standard Time
- HT
- Hawaii-Aleutian Time
- LT
- Local Time
- MD
- Mountain Daylight Time
- MS
- Mountain Standard Time
- MT
- Mountain Time
- ND
- Newfoundland Daylight Time
- NS
- Newfoundland Standard Time
- NT
- Newfoundland Time
- PD
- Pacific Daylight Time
- PS
- Pacific Standard Time
- PT
- Pacific Time
- TD
- Atlantic Daylight Time
- TS
- Atlantic Standard Time
- TT
- Atlantic Time
- UT
- Universal Time Coordinate
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BGN06 is the transaction set reference number of a previously sent transaction affected by the current transaction.
Code indicating type of action
- 2
- Change (Update)
Used to identify a transaction of additions, terminations and changes to the current enrollment.
- 4
- Verify
Used to identify a full enrollment transaction to verify that the sponsor's and payer's systems are synchronized.
- RX
- Replace
Used to identify a full enrollment transmission to be used to identify additions, terminations and changes that need to be applied to the payer's enrollment system.
Transaction Set Policy Number
To specify identifying information
- The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.
- Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set.
Code qualifying the Reference Identification
- 38
- Master Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
File Effective Date
To specify any or all of a date, a time, or a time period
- Required when specified in the contract. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 007
- Effective
- 090
- Report Start
- 091
- Report End
- 303
- Maintenance Effective
- 382
- Enrollment
- 388
- Payment Commencement
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Transaction Set Control Totals
To specify quantity information
- Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send.
Payer
To identify a party by type of organization, name, and code
- This loop identifies the payer. See section 1.5 for the definition of payer.
Code identifying an organizational entity, a physical location, property or an individual
- IN
- Insurer
Code designating the system/method of code structure used for Identification Code (67)
- 94
- Code assigned by the organization that is the ultimate destination of the transaction set
- FI
- Federal Taxpayer's Identification Number
- XV
- Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
Sponsor Name
To identify a party by type of organization, name, and code
- This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
Code identifying an organizational entity, a physical location, property or an individual
- P5
- Plan Sponsor
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
The identifier is the Employer Identification Number (EIN) issued by the IRS. The EIN has been adopted as the HIPAA Standard Unique Employer Identifier.
- 94
- Code assigned by the organization that is the ultimate destination of the transaction set
- FI
- Federal Taxpayer's Identification Number
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
TPA/Broker Name
To identify a party by type of organization, name, and code
- Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- BO
- Broker or Sales Office
- TV
- Third Party Administrator (TPA)
Code designating the system/method of code structure used for Identification Code (67)
- 94
- Code assigned by the organization that is the ultimate destination of the transaction set
- FI
- Federal Taxpayer's Identification Number
- XV
- Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Code identifying a party or other code
- This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
TPA/Broker Account Information
To specify account information
- Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.
Detail
Member Level Detail
To provide benefit information on insured entities
- Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
- Y
- Yes
Code indicating the relationship between two individuals or entities
- The value 18 must be used for the subscriber.;
- For dependents, this value identifies their relationship to the subscriber. For example, a daughter would be value 19.
- 01
- Spouse
- 03
- Father or Mother
- 04
- Grandfather or Grandmother
- 05
- Grandson or Granddaughter
- 06
- Uncle or Aunt
- 07
- Nephew or Niece
- 08
- Cousin
- 09
- Adopted Child
- 10
- Foster Child
- 11
- Son-in-law or Daughter-in-law
- 12
- Brother-in-law or Sister-in-law
- 13
- Mother-in-law or Father-in-law
- 14
- Brother or Sister
- 15
- Ward
- 16
- Stepparent
- 17
- Stepson or Stepdaughter
- 18
- Self
- 19
- Child
- 23
- Sponsored Dependent
Dependents between the ages of 19 and 25 not attending school; age qualifications may vary depending on policy.
- 24
- Dependent of a Minor Dependent
- 25
- Ex-spouse
- 26
- Guardian
- 31
- Court Appointed Guardian
- 38
- Collateral Dependent
Relative related by blood or marriage who resides in the home and is dependent on the insured for a major portion of their support.
- 53
- Life Partner
This is a partner that acts like a spouse without a legal marriage committment.
- 60
- Annuitant
- D2
- Trustee
- G8
- Other Relationship
- G9
- Other Relative
Code identifying the specific type of item maintenance
- 001
- Change
Use this code to indicate a change to an existing subscriber/dependent record.
- 021
- Addition
Use this code to add a subscriber or dependent.
- 024
- Cancellation or Termination
Use this code for cancellation, termination, or deletion of a subscriber or dependent.
- 025
- Reinstatement
Use this code for reinstatement of a cancelled subscriber/dependent record.
- 030
- Audit or Compare
Use this code when sending a full file (BGN08 =
4' orRX') to verify that the sponsor and payer databases are synchronized. See section 1.4.5, Update, Versus Full File Audits, Versus Full File Replacements, for additional information.
Code identifying the reason for the maintenance change
- 01
- Divorce
- 02
- Birth
- 03
- Death
- 04
- Retirement
- 05
- Adoption
- 06
- Strike
- 07
- Termination of Benefits
- 08
- Termination of Employment
- 09
- Consolidation Omnibus Budget Reconciliation Act (COBRA)
- 10
- Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
- 11
- Surviving Spouse
- 14
- Voluntary Withdrawal
- 15
- Primary Care Provider (PCP) Change
- 16
- Quit
- 17
- Fired
- 18
- Suspended
- 20
- Active
- 21
- Disability
- 22
- Plan Change
Use this code when a member changes from one Plan to a different Plan. This is not intended to identify changes to a Plan.
- 25
- Change in Identifying Data Elements
Use this code when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.
- 26
- Declined Coverage
Use this code when a member declined a previously active coverage.
- 27
- Pre-Enrollment
Use this code to enroll newborns prior to receiving the newborn's application.
- 28
- Initial Enrollment
Use this code the first time the member selected coverage with the Plan Sponsor.
- 29
- Benefit Selection
Use this code when a member changes benefits within a Plan.
- 31
- Legal Separation
- 32
- Marriage
- 33
- Personnel Data
Use this code for any data change that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.
- 37
- Leave of Absence with Benefits
- 38
- Leave of Absence without Benefits
- 39
- Lay Off with Benefits
- 40
- Lay Off without Benefits
- 41
- Re-enrollment
- 43
- Change of Location
Use this code to indicate a change of address.
- 59
- Non Payment
- AA
- Dissatisfaction with Office Staff
- AB
- Dissatisfaction with Medical Care/Services Rendered
- AC
- Inconvenient Office Location
- AD
- Dissatisfaction with Office Hours
- AE
- Unable to Schedule Appointments in a Timely Manner
- AF
- Dissatisfaction with Physician's Referral Policy
- AG
- Less Respect and Attention Time Given than to Other Patients
- AH
- Patient Moved to a New Location
- AI
- No Reason Given
- AJ
- Appointment Times not Met in a Timely Manner
- AL
- Algorithm Assigned Benefit Selection
- EC
- Member Benefit Selection
Use this code for initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice.
- XN
- Notification Only
Use this code in complete enrollment transmissions. This is used when INS03 is equal to 030 (Audit/Compare).
- XT
- Transfer
Use this code when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan.
The type of coverage under which benefits are paid
- A
- Active
- C
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
- S
- Surviving Insured
- T
- Tax Equity and Fiscal Responsibility Act (TEFRA)
Required if a member is being enrolled or disenrolled in Medicare, is currently in Medicare or has terminated or changed their Medicare enrollment. If not required by this implementation guide, do not send.
A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary
- 1
- Termination of Employment
- 2
- Reduction of work hours
- 3
- Medicare
- 4
- Death
- 5
- Divorce
- 6
- Separation
- 7
- Ineligible Child
- 8
- Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
- 9
- Layoff
- 10
- Leave of Absence
- ZZ
- Mutually Defined
Code showing the general employment status of an employee/claimant
- If this insurance enrollment is through a non-employment based program such as Medicare or Medicaid then this data element will contain the status of the subscriber in that program, rather than their employment status. Codes for non-employment based programs will be limited to "AC", Active and "TE", Terminated.
- AC
- Active
- AO
- Active Military - Overseas
- AU
- Active Military - USA
- FT
- Full-time
Full time active employee
- L1
- Leave of Absence
- PT
- Part-time
Part time Active Employee
- RT
- Retired
- TE
- Terminated
Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured
- F
- Full-time
- N
- Not a Student
- P
- Part-time
Code indicating a Yes or No condition or response
- INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value indicates an individual is not handicapped.
- N
- No
- Y
- Yes
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- INS12 is the date of death.
Code indicating the access to insured information
- R
- Restricted Access
- U
- Unrestricted Access
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
Member Policy Number
To specify identifying information
- The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.
- Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
The submitter sends the payer's pre-assigned Group or Policy Number.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Member Supplemental Identifier
To specify identifying information
- Required when sending additional identifying information on the member. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 3H
- Case Number
- 4A
- Personal Identification Number (PIN)
Use this code to transmit a password that is associated with the member's record.
- 6O
- Cross Reference Number
Used when further identification of a member is required for reporting, indexing, or other purpose as mutually agreed upon between the sender and receiver of the transaction set.
- 17
- Client Reporting Category
Used when further identification of a member is required under the insurance contract between the sponsor and the payer and allowed by federal and state regulations.
- 23
- Client Number
To be used to pass a payer specific identifier for a member. Not to be used after the HIPAA standard National Identifier for Individuals is implemented.
- ABB
- Personal ID Number
- D3
- National Council for Prescription Drug Programs Pharmacy Number
- DX
- Department/Agency Number
Use when members in a coverage group are set up as different departments or divisions under the terms of the insurance policy.
- F6
- Health Insurance Claim (HIC) Number
Use when reporting Medicare eligibility for a member until the National Identifier is mandated for use.
- P5
- Position Code
Use this code to transmit the title of the member's employment position.
- Q4
- Prior Identifier Number
Use to pass the Identifier Number under which the member had previous coverage with the payer. This could be the result of a change in employment or coverage that resulted in a new ID number being assigned but left the member covered by the same payer.
- Unit Number
Use when members in a coverage group are set up as different units under the terms of the insurance policy. Units may exist within another grouping such as division or department.
- ZZ
- Mutually Defined
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Identifier
To specify identifying information
- This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
- The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available.
Code qualifying the Reference Identification
- 0F
- Subscriber Number
The assignment of the Subscriber Number is designated within the Insurance Contract.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Member Level Dates
To specify any or all of a date, a time, or a time period
- Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.
- While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective.
Code specifying type of date or time, or both date and time
- 050
- Received
Used to identify the date an enrollment application is received.
- 286
- Retirement
- 296
- Initial Disability Period Return To Work
- 297
- Initial Disability Period Last Day Worked
- 300
- Enrollment Signature Date
- 301
- Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
- 303
- Maintenance Effective
This code is used to send the effective date of a change to an existing member's information, excluding changes made in Loop 2300.
- 336
- Employment Begin
- 337
- Employment End
- 338
- Medicare Begin
- 339
- Medicare End
- 340
- Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
- 341
- Consolidated Omnibus Budget Reconciliation Act (COBRA) End
- 350
- Education Begin
This is the start date for the student at the current educational institution.
- 351
- Education End
This is the expected graduation date the student at the current educational institution.
- 356
- Eligibility Begin
The date when a member could elect to enroll or begin benefits in any health care plan through the employer. This is not the actual begin date of coverage, which is conveyed in the DTP segment at position 2700.
- 357
- Eligibility End
The eligibility end date represents the last date of coverage for which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 02/28/2001.
- 383
- Adjusted Hire
- 385
- Credited Service Begin
The start date from which an employee's length of service, as defined in the plan document, will be calculated.
- 386
- Credited Service End
The end date to be used in the calculation of an employee's length of service, as defined in the plan document.
- 393
- Plan Participation Suspension
- 394
- Rehire
- 473
- Medicaid Begin
- 474
- Medicaid End
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Custodial Parent
To supply the full name of an individual or organizational entity
- Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.
- Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment.
Code identifying an organizational entity, a physical location, property or an individual
- S3
- Custodial Parent
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 34
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- ZZ
- Mutually Defined
Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.
Code identifying a party or other code
Custodial Parent Communications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- PQ
- Parent or Guardian
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Custodial Parent Street Address
To specify the location of the named party
- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
Custodial Parent City, State, ZIP Code
To specify the geographic place of the named party
- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Drop Off Location
To supply the full name of an individual or organizational entity
- Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Drop Off Location Street Address
To specify the location of the named party
- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
Drop Off Location City, State, ZIP Code
To specify the geographic place of the named party
- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Incorrect Member Name
To supply the full name of an individual or organizational entity
- Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.
- If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.
Code identifying an organizational entity, a physical location, property or an individual
- This code identifies that the information that follows is previously reported enrollment information that is being corrected.
- 70
- Prior Incorrect Insured
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 34
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- ZZ
- Mutually Defined
Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.
Code identifying a party or other code
- NM109 is the identifier that was previously sent in error. This allows matching with data on receiver's system.
Incorrect Member Demographics
To supply demographic information
- Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Code defining the marital status of a person
- B
- Registered Domestic Partner
- D
- Divorced
- I
- Single
- M
- Married
- R
- Unreported
- S
- Separated
- U
- Unmarried (Single or Divorced or Widowed)
This code should be used if the previous status is unknown.
- W
- Widowed
- X
- Legally Separated
Required when the members Race or Ethnicity is being corrected. If not required this implementation guide, do not send.
Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes
- 7
- Not Provided
- 8
- Not Applicable
- A
- Asian or Pacific Islander
- B
- Black
- C
- Caucasian
- D
- Subcontinent Asian American
- E
- Other Race or Ethnicity
- F
- Asian Pacific American
- G
- Native American
- H
- Hispanic
- I
- American Indian or Alaskan Native
- J
- Native Hawaiian
- N
- Black (Non-Hispanic)
- O
- White (Non-Hispanic)
- P
- Pacific Islander
- Z
- Mutually Defined
Code identifying a specific industry code list
- C056-02 and C056-03 are used to specify detailed information about race or ethnicity.
- RET
- Classification of Race or Ethnicity
Code indicating a code from a specific industry code list
Code indicating citizenship status
- 1
- U.S. Citizen
- 2
- Non-Resident Alien
- 3
- Resident Alien
- 4
- Illegal Alien
- 5
- Alien
- 6
- U.S. Citizen - Non-Resident
- 7
- U.S. Citizen - Resident
Code identifying a specific industry code list
- REC
- Race or Ethnicity Collection Code
Code indicating a code from a specific industry code list
- DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Member Employer
To supply the full name of an individual or organizational entity
- Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.
- This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop.
Code identifying an organizational entity, a physical location, property or an individual
- 36
- Employer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
This is the "HIPAA Employer Identifier".
- 34
- Social Security Number
Code identifying a party or other code
Member Employer Communications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- EP
- Employer Contact
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Member Employer Street Address
To specify the location of the named party
- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Member Employer City, State, ZIP Code
To specify the geographic place of the named party
- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Member Mailing Address
To supply the full name of an individual or organizational entity
- Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send.
Member Mail Street Address
To specify the location of the named party
Member Mail City, State, ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Member Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- This code identifies if this is a correction to a previous enrollment or if it is a new, or update, enrollment transaction.
- 74
- Corrected Insured
Use this code if this transmission is correcting the identifier information on a member already enrolled. Usage of this code requires the sending of an NM1 with code '70' in loop 2100B.
- IL
- Insured or Subscriber
Use this code for enrolling a new member or updating a member with no change in identifying information. The identifying information for a member is specified under the insurance contract between the sponsor and payer.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Code designating the system/method of code structure used for Identification Code (67)
- 34
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- ZZ
- Mutually Defined
Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.
Member Communications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- IP
- Insured Party
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Member Residence Street Address
To specify the location of the named party
- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
Member City, State, ZIP Code
To specify the geographic place of the named party
- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Member Demographics
To supply demographic information
- Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
This code is to be used only when the gender is unknown or when it can not be sent due to reporting restrictions.
Code defining the marital status of a person
- B
- Registered Domestic Partner
- D
- Divorced
- I
- Single
- M
- Married
- R
- Unreported
- S
- Separated
- U
- Unmarried (Single or Divorced or Widowed)
This code should be used if the previous status is unknown.
- W
- Widowed
- X
- Legally Separated
Required when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide, do not send.
Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes
- 7
- Not Provided
- 8
- Not Applicable
- A
- Asian or Pacific Islander
- B
- Black
- C
- Caucasian
- D
- Subcontinent Asian American
- E
- Other Race or Ethnicity
- F
- Asian Pacific American
- G
- Native American
- H
- Hispanic
- I
- American Indian or Alaskan Native
- J
- Native Hawaiian
- N
- Black (Non-Hispanic)
- O
- White (Non-Hispanic)
- P
- Pacific Islander
- Z
- Mutually Defined
Code identifying a specific industry code list
- C056-02 and C056-03 are used to specify detailed information about race or ethnicity.
- RET
- Classification of Race or Ethnicity
Code indicating a code from a specific industry code list
- CODE SOURCE 859: Classification of Race or Ethnicity
Code indicating citizenship status
- 1
- U.S. Citizen
- 2
- Non-Resident Alien
- 3
- Resident Alien
- 4
- Illegal Alien
- 5
- Alien
- 6
- U.S. Citizen - Non-Resident
- 7
- U.S. Citizen - Resident
Code identifying a specific industry code list
- REC
- Race or Ethnicity Collection Code
Code indicating a code from a specific industry code list
- DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
Employment Class
To provide class of employment information
- Required when sending additional employment class information on the member. If not required by this implementation guide, do not send.
Code indicating category of employee
- 01
- Union
- 02
- Non-Union
- 03
- Executive
- 04
- Non-Executive
- 05
- Management
- 06
- Non-Management
- 07
- Hourly
- 08
- Salaried
- 09
- Administrative
- 10
- Non-Administrative
- 11
- Exempt
- 12
- Non-Exempt
- 17
- Highly Compensated
- 18
- Key-Employee
- 19
- Bargaining
- 20
- Non-Bargaining
- 21
- Owner
- 22
- President
- 23
- Vice President
Code indicating category of employee
- 01
- Union
- 02
- Non-Union
- 03
- Executive
- 04
- Non-Executive
- 05
- Management
- 06
- Non-Management
- 07
- Hourly
- 08
- Salaried
- 09
- Administrative
- 10
- Non-Administrative
- 11
- Exempt
- 12
- Non-Exempt
- 17
- Highly Compensated
- 18
- Key-Employee
- 19
- Bargaining
- 20
- Non-Bargaining
- 21
- Owner
- 22
- President
- 23
- Vice President
Code indicating category of employee
- 01
- Union
- 02
- Non-Union
- 03
- Executive
- 04
- Non-Executive
- 05
- Management
- 06
- Non-Management
- 07
- Hourly
- 08
- Salaried
- 09
- Administrative
- 10
- Non-Administrative
- 11
- Exempt
- 12
- Non-Exempt
- 17
- Highly Compensated
- 18
- Key-Employee
- 19
- Bargaining
- 20
- Non-Bargaining
- 21
- Owner
- 22
- President
- 23
- Vice President
Member Income
To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions
- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
Code indicating frequency or type of activities or actions being reported
- ICM01 is the frequency at which an individual's wages are paid.
- 1
- Weekly
- 2
- Biweekly
- 3
- Semimonthly
- 4
- Monthly
- 6
- Daily
- 7
- Annual
- 8
- Two Calendar Months
- 9
- Lump-Sum Separation Allowance
- B
- Year-to-Date
- C
- Single
- H
- Hourly
- Q
- Quarterly
- S
- Semiannual
- U
- Unknown
Monetary amount
- ICM02 is the yearly wages amount.
Numeric value of quantity
- ICM03 is the weekly hours.
Code which identifies a specific location
- ICM04 is the employer location qualifier such as a department number.
The salary grade code assigned by the employer
Member Policy Amounts
To indicate the total monetary amount
- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
Code to qualify amount
- B9
- Co-insurance - Actual
This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.
- C1
- Co-Payment Amount
- D2
- Deductible Amount
- EBA
- Expected Expenditure Amount
- FK
- Other Unlisted Amount
- P3
- Premium Amount
- R
- Spend Down
Member Health Information
To provide health information
- Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send.
Code indicating a specific health situation
- N
- None
- S
- Substance Abuse
- T
- Tobacco Use
- U
- Unknown
- X
- Tobacco Use and Substance Abuse
Vertical dimension of an object measured when the object is in the upright position
- The height must be reported in inches.
Numeric value of weight
- HLH03 is the current weight in pounds.
Member Language
To specify language, type of usage, and proficiency or fluency
- Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.
- Any need to send/collect this information will need to be contained in the trading partner agreement.
Code designating the system/method of code structure used for Identification Code (67)
- LD
- NISO Z39.53 Language Codes
- LE
- ISO 639 Language Codes
Code identifying a party or other code
- LUI02 is the language code.
A free-form description to clarify the related data elements and their content
- LUI03 is the name of the language.
Code indicating the use of a language
- 5
- Language Reading
- 6
- Language Writing
- 7
- Language Speaking
- 8
- Native Language
Member School
To supply the full name of an individual or organizational entity
- Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- M8
- Educational Institution
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Member School Commmunications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- SK
- School Clerk
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Member School Street Address
To specify the location of the named party
- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Member School City, State, ZIP Code
To specify the geographic place of the named party
- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Responsible Person
To supply the full name of an individual or organizational entity
- Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 6Y
- Case Manager
- 9K
- Key Person
- E1
- Person or Other Entity Legally Responsible for a Child
Used to identify a legal indemnity situation.
This code is used when a Qualified Medical Child Support Order (QMSCO) is present.
- EI
- Executor of Estate
This is used when the subscriber is deceased and the executor/responsible party is other than a surviving spouse.
- EXS
- Ex-spouse
This is used to identify a separated spouse under a separation agreement, or that the member is the divorced spouse and self responsible. This is NOT USED to identify the custodial parent for dependent children after a divorce.
- GB
- Other Insured
- GD
- Guardian
- J6
- Power of Attorney
- LR
- Legal Representative
- QD
- Responsible Party
- S1
- Parent
- TZ
- Significant Other
- X4
- Spouse
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 34
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- ZZ
- Mutually Defined
Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.
Code identifying a party or other code
Responsible Person Communications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- RP
- Responsible Person
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Responsible Person Street Address
To specify the location of the named party
- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
Responsible Person City, State, ZIP Code
To specify the geographic place of the named party
- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Disability Information
To supply disability information
- Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send.
Code identifying the disability status of the individual
- 1
- Short Term Disability
- 2
- Long Term Disability
- 3
- Permanent or Total Disability
- 4
- No Disability
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- DX
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
- ZZ
- Mutually Defined
To be used for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - Diagnosis.
CODE SOURCE: 897 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
Code value for describing a medical condition or procedure
- DSB08 is the functional status code for the disability.
Disability Eligibility Dates
To specify any or all of a date, a time, or a time period
- This segment is used to send the first and last date of disability.
- Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 360
- Initial Disability Period Start
- 361
- Initial Disability Period End
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Health Coverage
To provide information on health coverage
- Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.
- Refer to section 1.4.4 "Termination" for additional information relative to removing a member's coverage.
Code identifying the specific type of item maintenance
- Required to identify the specific type of item maintenance.
- 001
- Change
- 002
- Delete
Use this code for deleting an incorrect coverage record.
- 021
- Addition
- 024
- Cancellation or Termination
Use this code for cancelling/terminating a coverage.
- 025
- Reinstatement
- 026
- Correction
This code is used to correct an incorrect record.
- 030
- Audit or Compare
- 032
- Employee Information Not Applicable
Certain situations, such as military duty and CHAMPUS/TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscribers are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents.
Code identifying a group of insurance products
- AG
- Preventative Care/Wellness
- AH
- 24 Hour Care
- AJ
- Medicare Risk
- AK
- Mental Health
- DCP
- Dental Capitation
This identifies a dental managed care organization (DMO).
- DEN
- Dental
- EPO
- Exclusive Provider Organization
- FAC
- Facility
- HE
- Hearing
- HLT
- Health
Includes both hospital and professional coverage.
- HMO
- Health Maintenance Organization
- LTC
- Long-Term Care
- LTD
- Long-Term Disability
- MM
- Major Medical
- MOD
- Mail Order Drug
- PDG
- Prescription Drug
- POS
- Point of Service
- PPO
- Preferred Provider Organization
- PRA
- Practitioners
- STD
- Short-Term Disability
- UR
- Utilization Review
- VIS
- Vision
A description or number that identifies the plan or coverage
Code indicating the level of coverage being provided for this insured
- See section 1.4.6, Coverage Levels and Dependents, for additional information.
- CHD
- Children Only
- DEP
- Dependents Only
- E1D
- Employee and One Dependent
For this code, the dependent is a non-spouse dependent. This code is not used for identification of Employee and Spouse. See code ESP.
- E2D
- Employee and Two Dependents
- E3D
- Employee and Three Dependents
- E5D
- Employee and One or More Dependents
- E6D
- Employee and Two or More Dependents
- E7D
- Employee and Three or More Dependents
- E8D
- Employee and Four or More Dependents
- E9D
- Employee and Five or More Dependents
- ECH
- Employee and Children
- EMP
- Employee Only
- ESP
- Employee and Spouse
- FAM
- Family
- IND
- Individual
- SPC
- Spouse and Children
- SPO
- Spouse Only
- TWO
- Two Party
Code indicating a Yes or No condition or response
- HD09 is a late enrollee indicator. A "Y" value indicates the insured is a late enrollee, which can result in a reduction of benefits; an "N" value indicates the insured is a regular enrollee.
- N
- No
- Y
- Yes
Health Coverage Dates
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 300
- Enrollment Signature Date
- 303
- Maintenance Effective
This is the effective date of a change where a member's coverage is not being added or removed.
- 343
- Premium Paid to Date End
- 348
- Benefit Begin
This is the effective date of coverage. This code must always be sent when adding or reinstating coverage.
- 349
- Benefit End
The termination date represents the last date of coverage in which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 2/28/01.
- 543
- Last Premium Paid Date
- 695
- Previous Period
This value is only to be used when reporting Previous Coverage Months.
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
This value is only to be used when reporting Previous Coverage Months.
Expression of a date, a time, or range of dates, times or dates and times
Health Coverage Policy
To indicate the total monetary amount
- Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
Code to qualify amount
- B9
- Co-insurance - Actual
This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.
- C1
- Co-Payment Amount
- D2
- Deductible Amount
- EBA
- Expected Expenditure Amount
- FK
- Other Unlisted Amount
- P3
- Premium Amount
- R
- Spend Down
Health Coverage Policy Number
To specify identifying information
- Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Required when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the contract between the sponsor (sender) and payer (receiver); if not required may be sent at the sender's discretion.
- 9V
- Payment Category
- 17
- Client Reporting Category
- CE
- Class of Contract Code
- E8
- Service Contract (Coverage) Number
- M7
- Medical Assistance Category
- PID
- Program Identification Number
- RB
- Rate code number
- X9
- Internal Control Number
- XM
- Issuer Number
- XX1
- Special Program Code
- XX2
- Service Area Code
- ZX
- County Code
- ZZ
- Mutually Defined
Use this code for the Payment Plan Type Code (Annual or Quarterly) until a standard code is assigned.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Prior Coverage Months
To specify identifying information
- Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act.
Code qualifying the Reference Identification
- Unit Number
This code is used in this implementation guide to indicate that the value in REF02 is the response required under the portability provisions of HIPAA.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Indicator identifying the number of prior months insurance coverage that may apply under the portability provisions of the Health Insurance Portability and Accountability Act.
- This field will contain the number of months of prior health insurance coverage that meets the portability requirements of the HIPAA certification requirements. To be sent on new enrollments when available.
Identification Card
To provide notification to produce replacement identification card(s)
- Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.
- An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card.
A description or number that identifies the plan or coverage
- If no additional information is needed, this element will be sent as a single zero.
Code identifying the type of identification card
- This code is used to identify that the card issued will be specific to the coverage identified in the related HD segment.
- D
- Dental Insurance
- H
- Health Insurance
- P
- Prescription Drug Service Drug Insurance
Numeric value of quantity
- IDC03 is the number of cards being requested.
- Only non-negative integer values are to be sent.
Code indicating type of action
- IDC04 is the reason for the card being requested, i.e., add or a change.
- 1
- Add
- 2
- Change (Update)
- RX
- Replace
Use when requesting replacement cards with no change to data.
Provider Information
To reference a line number in a transaction set
- Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.
- Use one iteration of the loop to identify each applicable health care service provider.
- The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.
Number assigned for differentiation within a transaction set
- This is a sequential number representing the number of loops for this insured person. Begin with 1 for each insured person.
Provider Name
To supply the full name of an individual or organizational entity
- The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2.
Code identifying an organizational entity, a physical location, property or an individual
- 1X
- Laboratory
- 3D
- Obstetrics and Gynecology Facility
- 80
- Hospital
- FA
- Facility
- OD
- Doctor of Optometry
- P3
- Primary Care Provider
- QA
- Pharmacy
- QN
- Dentist
- Y2
- Managed Care Organization
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 34
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- FI
- Federal Taxpayer's Identification Number
- SV
- Service Provider Number
This is a number assigned by the payer used to identify a provider.
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code describing entity relationship
- NM110 and NM111 further define the type of entity in NM101.
- This element indicates whether or not the member is an existing patient of the provider.
- 25
- Established Patient
- 26
- Not Established Patient
- 72
- Unknown
Provider Address
To specify the location of the named party
- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Provider Communications Numbers
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- AP
- Alternate Telephone
- BN
- Beeper Number
- CP
- Cellular Phone
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
Complete communications number including country or area code when applicable
Provider Change Reason
To indicate action to be taken for the location specified and to qualify the location specified
- Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- PLA03 is the effective date for the action identified in PLA01.
- This is the effective date of the change of PCP.
Code identifying the reason for the maintenance change
- If none of the specific Maintenance Reasons apply, send 'AI', No Reason Given.
- 14
- Voluntary Withdrawal
- 22
- Plan Change
- 46
- Current Customer Information File in Error
- AA
- Dissatisfaction with Office Staff
- AB
- Dissatisfaction with Medical Care/Services Rendered
- AC
- Inconvenient Office Location
- AD
- Dissatisfaction with Office Hours
- AE
- Unable to Schedule Appointments in a Timely Manner
- AF
- Dissatisfaction with Physician's Referral Policy
- AG
- Less Respect and Attention Time Given than to Other Patients
- AH
- Patient Moved to a New Location
- AI
- No Reason Given
- AJ
- Appointment Times not Met in a Timely Manner
Coordination of Benefits
To supply information on coordination of benefits
- Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.
Code identifying the insurance carrier's level of responsibility for a payment of a claim
- P
- Primary
- S
- Secondary
- T
- Tertiary
- U
- Unknown
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- COB02 is the policy number.
Code identifying whether there is a coordination of benefits
- 1
- Coordination of Benefits
- 5
- Unknown
- 6
- No Coordination of Benefits
This code is sent when it has been determined that there is no COB.
Code identifying the classification of service
- 1
- Medical Care
- 35
- Dental Care
- 48
- Hospital - Inpatient
- 50
- Hospital - Outpatient
- 54
- Long Term Care
- 89
- Free Standing Prescription Drug
- 90
- Mail Order Prescription Drug
- A4
- Psychiatric
- AG
- Skilled Nursing Care
- AL
- Vision (Optometry)
- BB
- Partial Hospitalization (Psychiatric)
Additional Coordination of Benefits Identifiers
To specify identifying information
- Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
- Use the Social Security Number until the National ID Number for individuals is available.
Code qualifying the Reference Identification
- 6P
- Group Number
- 60
- Account Suffix Code
- SY
- Social Security Number
The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.
- ZZ
- Mutually Defined
Mutually Defined, will be used in this REF01 for National Individual Identifier until a standard code is defined.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Coordination of Benefits Eligibility Dates
To specify any or all of a date, a time, or a time period
- Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 344
- Coordination of Benefits Begin
- 345
- Coordination of Benefits End
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Coordination of Benefits Related Entity
To supply the full name of an individual or organizational entity
- Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 36
- Employer
- GW
- Group
- IN
- Insurer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
- NI
- National Association of Insurance Commissioners (NAIC) Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Code identifying a party or other code
Coordination of Benefits Related Entity Address
To specify the location of the named party
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Coordination of Benefits Other Insurance Company City, State, ZIP Code
To specify the geographic place of the named party
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Administrative Communications Contact
To identify a person or office to whom administrative communications should be directed
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- CN
- General Contact
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
Loop Header
To indicate that the next segment begins a loop
The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE
Member Reporting Categories
To reference a line number in a transaction set
- Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.
Number assigned for differentiation within a transaction set
- Use this sequential non-negative integer for LX loops for this member's additional reporting categories.
Reporting Category
To identify a party by type of organization, name, and code
- Required to specify the name of the reporting category of the member's participating entity.
Reporting Category Reference
To specify identifying information
- Required to specify the reference identifier associated with the reporting category of the member's participating entity.
Code qualifying the Reference Identification
- 00
- Contracting District Number
- 3L
- Branch Identifier
- 6M
- Application Number
- 9V
- Payment Category
- 9X
- Account Category
- 17
- Client Reporting Category
- 18
- Plan Number
- 19
- Division Identifier
- 26
- Union Number
- GE
- Geographic Number
- LU
- Location Number
- PID
- Program Identification Number
- XX1
- Special Program Code
- XX2
- Service Area Code
- YY
- Geographic Key
- ZZ
- Mutually Defined
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Reporting Category Date
To specify any or all of a date, a time, or a time period
- Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
- Use this segment to associate a date or date range with a reporting category.
Code specifying type of date or time, or both date and time
- 007
- Effective
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
A range of dates expressed in the format CCYYMMDD-CCYYMMDD where CCYY is the numerical expression of the century CC and year YY. MM is the numerical expression of the month within the year, and DD is the numerical expression of the day within the year; the first occurrence of CCYYMMDD is the beginning date and the second occurrence is the ending date.
Expression of a date, a time, or range of dates, times or dates and times
Loop Trailer
To indicate that the loop immediately preceding this segment is complete
The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. For example, start with the number 0001 and increment from there. This number must be unique within a specific group and interchange, but the number can repeat in other groups and interchanges.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
834 Inbound Envelope
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~
834 Outbound Envelope
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~
Example 1: Enroll an Employee in Multiple Health Care Insurance Products
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~
Example 10: Reinstate member eligibility (INS)
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025**A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*202443307~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~
Example 2: Add a Dependent (Full-time Student) to an Existing Enrollment
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*021*28*A****F~
REF*0F*123456789~
REF*1L*123456001~
DTP*351*D8*19980515~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
NM1*M8*2*PENN STATE UNIVERSITY~
HD*021**HLT~
DTP*348*D8*19960601~
SE*15*12345~
GE*1*000000103~
IEA*1*000000103~
Example 3: Enroll an Employee in a Managed Care Product
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*202443307~
REF*1L*123456001~
DTP*356*D8*19960112~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
PER*IP**HP*7172343334*WP*7172341240~
N3*1715 SOUTHWIND AVENUE~
N4*ANYTOWN*PA*171110000~
DMG*D8*19700614*M~
HD*021**HMO~
DTP*348*D8*19960601~
LX*01~
NM1*P3*1*BROWN*BERNARD**DR**SV*143766*25~
SE*18*12345~
GE*1*000000103~
IEA*1*000000103~
Example 4: Add Subscriber Coverage
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001*22*A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*2024433307~
HD*021**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~
Example 5: Change subscriber information
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5*GENERIC INC*FI*000111000~
N1*IN*ABC INSURANCE*FI*654456654~
INS*Y*18*001*25*A***FT~
REF*0F*123456789~
REF*1L*123456001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19500415*M~
NM1*70*1*DOE*JAMES*E~
DMG*D8*19500416*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~
Example 6: Cancel a dependent
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*024*07*A~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19960801~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~
Example 7: Terminate Eligibility for a Subscriber
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*024*08*A***TE~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~
Example 8: Reinstate an Employee
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*303*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*11*12345~
GE*1*000000103~
IEA*1*000000103~
Example 9: Reinstate the Employee at the Coverage (HD) Level
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025**A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*202443307~
HD*025**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~
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