Sana

X12 834 Sana Inbound - Standard

X12 Release 5010

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.

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA

Interchange Control Header

RequiredMax use 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

ISA-01 · I01 · Authorization Information Qualifier · Required · Code identifying the type of information in the Authorization Information · 00 No Authorization Information Present (No Meaningful Information in I02)

ISA-02 · I02 · Authorization Information · Required Min 10 Max 10 · 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)

ISA-03 · I03 · Security Information Qualifier · Required · Code identifying the type of information in the Security Information · 00 No Security Information Present (No Meaningful Information in I04)

ISA-04 · I04 · Security Information · Required Min 10 Max 10 · 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)

ISA-05 · I05 · Interchange ID Qualifier · Required Min 2 Max 2 · Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified · Codes 01 Duns (Dun & Bradstreet) 02 SCAC (Standard Carrier Alpha Code) 03 FMC (Federal Maritime Commission) 04 IATA (International Air Transport Association) 07 Global Location Number (GLN) 08 UCC EDI Communications ID (Comm ID) 09 X.121 (CCITT) 10 Department of Defense (DoD) Activity Address Code 11 DEA (Drug Enforcement Administration) 12 Phone (Telephone Companies) 13 UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code) 14 Duns Plus Suffix 15 Petroleum Accountants Society of Canada Company Code 16 Duns Number With 4-Character Suffix 17 American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit) 18 Association of American Railroads (AAR) Standard Distribution Code 19 EDI Council of Australia (EDICA) Communications ID Number (COMM ID) 20 Health Industry Number (HIN) 21 Integrated Postsecondary Education Data System, or (IPEDS) 22 Federal Interagency Commission on Education, or FICE 23 National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES 24 The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP 25 ACT, Inc. 4-Digit Code of Postsecondary Institutions. 26 Statistics of Canada List of Postsecondary Institutions 27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA) 28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA) 29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA) 30 U.S. Federal Tax Identification Number 31 Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC) 32 U.S. Federal Employer Identification Number (FEIN) 33 National Association of Insurance Commissioners Company Code (NAIC) 34 Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA) 35 Statistics Canada Canadian College Student Information System Institution Codes 36 Statistics Canada University Student Information System Institution Codes 37 Society of Property Information Compilers and Analysts 38 The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions AM Association Mexicana del Codigo de Producto (AMECOP) Communication ID NR National Retail Merchants Association (NRMA) - Assigned SA User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System SN Standard Address Number ZZ Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required Min 15 Max 15 · 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

ISA-07 · I05 · Interchange ID Qualifier · Required Min 2 Max 2 · Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified · Codes 01 Duns (Dun & Bradstreet) 02 SCAC (Standard Carrier Alpha Code) 03 FMC (Federal Maritime Commission) 04 IATA (International Air Transport Association) 07 Global Location Number (GLN) 08 UCC EDI Communications ID (Comm ID) 09 X.121 (CCITT) 10 Department of Defense (DoD) Activity Address Code 11 DEA (Drug Enforcement Administration) 12 Phone (Telephone Companies) 13 UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code) 14 Duns Plus Suffix 15 Petroleum Accountants Society of Canada Company Code 16 Duns Number With 4-Character Suffix 17 American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit) 18 Association of American Railroads (AAR) Standard Distribution Code 19 EDI Council of Australia (EDICA) Communications ID Number (COMM ID) 20 Health Industry Number (HIN) 21 Integrated Postsecondary Education Data System, or (IPEDS) 22 Federal Interagency Commission on Education, or FICE 23 National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES 24 The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP 25 ACT, Inc. 4-Digit Code of Postsecondary Institutions. 26 Statistics of Canada List of Postsecondary Institutions 27 Carrier Identification Number as assigned by Health Care Financing Administration (HCFA) 28 Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA) 29 Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA) 30 U.S. Federal Tax Identification Number 31 Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC) 32 U.S. Federal Employer Identification Number (FEIN) 33 National Association of Insurance Commissioners Company Code (NAIC) 34 Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA) 35 Statistics Canada Canadian College Student Information System Institution Codes 36 Statistics Canada University Student Information System Institution Codes 37 Society of Property Information Compilers and Analysts 38 The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions AM Association Mexicana del Codigo de Producto (AMECOP) Communication ID NR National Retail Merchants Association (NRMA) - Assigned SA User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System SN Standard Address Number ZZ Mutually Defined

ISA-08 · I07 · Interchange Receiver ID · Required Min 15 Max 15 · 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

ISA-09 · I08 · Interchange Date · Required YYMMDD format · Date of the interchange

ISA-10 · I09 · Interchange Time · Required HHMM format · Time of the interchange

ISA-11 · I65 · Repetition Separator · Required Min 1 Max 1 · 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

ISA-12 · I11 · Interchange Control Version Number · Required · Code specifying the version number of the interchange control segments · 00501 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required Min 9 Max 9 · A control number assigned by the interchange sender

ISA-14 · I13 · Acknowledgment Requested · Required Min 1 Max 1 · Code indicating sender's request for an interchange acknowledgment · 0 No Interchange Acknowledgment Requested 1 Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required Min 1 Max 1 · Code indicating whether data enclosed by this interchange envelope is test, production or information · I Information P Production Data T Test Data

ISA-16 · I15 · Component Element Separator · Required Min 1 Max 1 · 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

GS

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

GS-01 · 479 · Functional Identifier Code · Required · Code identifying a group of application related transaction sets · BE Benefit Enrollment and Maintenance (834)

GS-02 · 142 · Application Sender's Code · Required Min 2 Max 15 · Code identifying party sending transmission; codes agreed to by trading partners

GS-03 · 124 · Application Receiver's Code · Required Min 2 Max 15 · Code identifying party receiving transmission; codes agreed to by trading partners

GS-04 · 373 · Date · Required CCYYMMDD format · Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05 · 337 · Time · Required HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format · 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)

GS-06 · 28 · Group Control Number · Required Min 1 Max 9 · Assigned number originated and maintained by the sender

GS-07 · 455 · Responsible Agency Code · Required Min 1 Max 2 · 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

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · 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 · 005010 Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Heading

ST

0100

Transaction Set Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

ST-01 · 143 · Transaction Set Identifier Code · Required · 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

ST-02 · 329 · Transaction Set Control Number · Required Min 4 Max 9 · Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

ST-03 · 1705 · Implementation Convention Reference · Optional Min 1 Max 35 · 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.

BGN

0200

Beginning Segment

RequiredMax use 1

To indicate the beginning of a transaction set

Example

If Time Code (BGN-05) is present, then Time (BGN-04) is required

BGN-01 · 353 · Transaction Set Purpose Code · Required Min 2 Max 2 · Code identifying purpose of transaction set

BGN-02 · 127 · Reference Identification · Required Min 1 Max 50 · Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier BGN02 is the transaction set reference number.

BGN-03 · 373 · Date · Required CCYYMMDD format · Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year BGN03 is the transaction set date.

BGN-04 · 337 · Time · Optional HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format · 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.

BGN-05 · 623 · Time Code · Optional Min 2 Max 2 · 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.

BGN-08 · 306 · Action Code · Optional Min 1 Max 2 · Code indicating type of action

REF

0300

Reference Information

OptionalMax use >1

To specify identifying information

REF-01 · 128 · Reference Identification Qualifier · Optional Min 2 Max 3 · Code qualifying the Reference Identification

DTP

0400

Date or Time or Period

OptionalMax use >1

To specify any or all of a date, a time, or a time period

DTP-01 · 374 · Date/Time Qualifier · Required · Code specifying type of date or time, or both date and time · 007 Effective 303 Maintenance Effective

DTP-02 · 1250 · Date Time Period Format Qualifier · Required Min 2 Max 3 · 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.

DTP-03 · 1251 · Date Time Period · Required Min 1 Max 35 · Expression of a date, a time, or range of dates, times or dates and times

QTY

0600

Quantity Information

OptionalMax use >1

To specify quantity information

• The QTY segment is used to record the total number of subscribers and dependents in the transaction set.

QTY-01 · 673 · Quantity Qualifier · Required · Code specifying the type of quantity · DT Dependent Total ET Employee Total TO Total

QTY-02 · 380 · Quantity · Optional Min 1 Max 15 · Numeric value of quantity

1000 Loop

RequiredMax >1

N1

0700

Party Identification

RequiredMax use 1

To identify a party by type of organization, name, and code

• At least one iteration of loop 1000 is required to identify the sender or receiver.

Example

At least one of Name (N1-02) or Identification Code Qualifier (N1-03) is required

If either Identification Code Qualifier (N1-03) or Identification Code (N1-04) is present, then the other is required

N1-01 · 98 · Entity Identifier Code · Required · Code identifying an organizational entity, a physical location, property or an individual · IN Insurer P5 Plan Sponsor TV Third Party Administrator (TPA)

N1-02 · 93 · Name · Required Min 1 Max 60 · Free-form name

N1-03 · 66 · Identification Code Qualifier · Optional · Code designating the system/method of code structure used for Identification Code (67) · 24 Employer's Identification Number FI Federal Taxpayer's Identification Number

N1-04 · 67 · Identification Code · Optional Min 2 Max 80 · 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.

Detail

2000 Loop

RequiredMax >1

INS

0100

Insured Benefit

RequiredMax use 1

To provide benefit information on insured entities

• A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information.

INS-01 · 1073 · Yes/No Condition or Response Code · Required · 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

INS-02 · 1069 · Individual Relationship Code · Required · Code indicating the relationship between two individuals or entities · 01 Spouse 18 Self 19 Child 53 Life Partner

INS-03 · 875 · Maintenance Type Code · Required Min 3 Max 3 · Code identifying the specific type of item maintenance

INS-04 · 1203 · Maintenance Reason Code · Optional Min 2 Max 3 · Code identifying the reason for the maintenance change

INS-05 · 1216 · Benefit Status Code · Optional · The type of coverage under which benefits are paid · A Active C Consolidated Omnibus Budget Reconciliation Act (COBRA)

INS-06 · C052 · Medicare Status Code

C052-01 · 1218 · Medicare Plan Code · Required Min 1 Max 1 · Code identifying the Medicare Plan

INS-07 · 1219 · Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code · Optional Min 1 Max 2 · A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary

INS-08 · 584 · Employment Status Code · Optional · Code showing the general employment status of an employee/claimant · AC Active FT Full-time PT Part-time TE Terminated

INS-09 · 1220 · Student Status Code · Optional Min 1 Max 1 · Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured

INS-10 · 1073 · Yes/No Condition or Response Code · Optional Min 1 Max 1 · 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.

REF

0200

Reference Information

RequiredMax use 2

To specify identifying information

• One REF segment is required to link the dependent(s) to the subscriber.
• One REF segment is required to link the members to an employer group.

Usage notes

For members, two items are required (0F and 1L)
For dependents, only 0F is required

REF-01 · 128 · Reference Identification Qualifier · Required · Code qualifying the Reference Identification · 0F Subscriber SSN 1L Group Number This is the group number generated by Sana.

REF-02 · 127 · Reference Identification · Required Min 1 Max 50 · Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF-03 · 352 · Sub-group · Optional Min 1 Max 80 · Defines the sub-group that this member should be categorized under. Only used when REF02 is 1L (Group Number)

DTP

0250

Date or Time or Period

OptionalMax use 2

To specify any or all of a date, a time, or a time period

DTP-01 · 374 · Date/Time Qualifier · Required · Code specifying type of date or time, or both date and time · 336 Employment Begin 337 Employment End

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · 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

DTP-03 · 1251 · Date Time Period · Required Min 8 Max 35 · Expression of a date, a time, or range of dates, times or dates and times

2100 Loop

RequiredMax >1

NM1

0300

Individual or Organizational Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example

If either Identification Code Qualifier (NM1-08) or Identification Code (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Code identifying an organizational entity, a physical location, property or an individual · IL Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Code qualifying the type of entity NM102 qualifies NM103. · 1 Person

NM1-03 · 1035 · Name Last or Organization Name · Required Min 1 Max 60 · Individual last name or organizational name

NM1-04 · 1036 · Name First · Required Min 1 Max 35 · Individual first name

NM1-05 · 1037 · Name Middle · Optional Min 1 Max 25 · Individual middle name or initial

NM1-06 · 1038 · Name Prefix · Optional Min 1 Max 10 · Prefix to individual name

NM1-07 · 1039 · Name Suffix · Optional Min 1 Max 10 · Suffix to individual name

NM1-08 · 66 · Identification Code Qualifier · Optional · Code designating the system/method of code structure used for Identification Code (67) · 34 Social Security Number

NM1-09 · 67 · Identification Code · Optional Min 9 Max 9 · Code identifying a party or other code

PER

0400

Administrative Communications Contact

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Example

If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Code identifying the major duty or responsibility of the person or group named · IP Insured Party

PER-03 · 365 · Communication Number Qualifier · Required · Code identifying the type of communication number · CP Cellular Phone EM Electronic Mail HP Home Phone Number TE Telephone

PER-04 · 364 · Communication Number · Required Min 1 Max 256 · Complete communications number including country or area code when applicable

PER-05 · 365 · Communication Number Qualifier · Optional · Code identifying the type of communication number · CP Cellular Phone EM Electronic Mail HP Home Phone Number TE Telephone

PER-06 · 364 · Communication Number · Optional Min 1 Max 256 · Complete communications number including country or area code when applicable

PER-07 · 365 · Communication Number Qualifier · Optional · Code identifying the type of communication number · CP Cellular Phone EM Electronic Mail TE Telephone

PER-08 · 364 · Communication Number · Optional Min 1 Max 256 · Complete communications number including country or area code when applicable

N3

0500

Party Location

RequiredMax use 1

To specify the location of the named party

N3-01 · 166 · Address Information · Required Min 1 Max 55 · Address information

N3-02 · 166 · Address Information · Optional Min 1 Max 55 · Address information

N4

0600

Geographic Location

RequiredMax use 1

To specify the geographic place of the named party

N4-01 · 19 · City Name · Required Min 2 Max 30 · Free-form text for city name A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

N4-02 · 156 · State or Province Code · Required Min 2 Max 2 · 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.

N4-03 · 116 · Postal Code · Required Min 5 Max 9 · Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

DMG

0800

Demographic Information

OptionalMax use 1

To supply demographic information

DMG-01 · 1250 · Date Time Period Format Qualifier · Required · Code indicating the date format, time format, or date and time format · D8 Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Date Time Period · Required Min 8 Max 8 · Expression of a date, a time, or range of dates, times or dates and times DMG02 is the date of birth.

DMG-03 · 1068 · Gender Code · Required · Code indicating the sex of the individual · F Female M Male U Unknown

DMG-04 · 1067 · Marital Status Code · Optional Min 1 Max 1 · Code defining the marital status of a person

DMG-06 · 1066 · Citizenship Status Code · Optional Min 1 Max 2 · Code indicating citizenship status

ICM

1100

Individual Income

OptionalMax use 1

To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions

ICM-01 · 594 · Frequency Code · Required Min 1 Max 1 · Code indicating frequency or type of activities or actions being reported ICM01 is the frequency at which an individual's wages are paid.

ICM-02 · 782 · Monetary Amount · Required Min 1 Max 15 · Monetary amount ICM02 is the yearly wages amount.

ICM-03 · 380 · Quantity · Optional Min 1 Max 15 · Numeric value of quantity ICM03 is the weekly hours.

ICM-04 · 310 · Location Identifier · Optional Min 1 Max 30 · Code which identifies a specific location ICM04 is the employer location qualifier such as a department number.

HLH

1300

Health Information

OptionalMax use 1

To provide health information

HLH-01 · 1212 · Health-Related Code · Optional Min 1 Max 1 · Code indicating a specific health situation

2300 Loop

RequiredMax >1

HD

2600

Health Coverage

RequiredMax use 1

To provide information on health coverage

HD-01 · 875 · Maintenance Type Code · Required Min 3 Max 3 · Code identifying the specific type of item maintenance

HD-02 · 1203 · Maintenance Reason Code · Optional Min 2 Max 3 · Code identifying the reason for the maintenance change

HD-03 · 1205 · Insurance Line Code · Required · Code identifying a group of insurance products · HLT Health

HD-05 · 1207 · Coverage Level Code · Optional Min 3 Max 3 · Code indicating the level of coverage being provided for this insured

DTP

2700

Date or Time or Period

RequiredMax use 10

To specify any or all of a date, a time, or a time period

DTP-01 · 374 · Date/Time Qualifier · Required Max use 2 · Code specifying type of date or time, or both date and time · 348 Benefit Begin 349 Benefit End

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · 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

DTP-03 · 1251 · Date Time Period · Required Min 8 Max 8 · Expression of a date, a time, or range of dates, times or dates and times

REF

2900

Reference Information

RequiredMax use 1

To specify identifying information

REF-01 · 128 · Reference Identification Qualifier · Required · Code qualifying the Reference Identification · 1L Policy Number Unique plan ID generated by Sana

REF-02 · 127 · Reference Identification · Required Min 36 Max 36 [0-9a-f]{8}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{12} RegEx pattern · Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SE

6900

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

SE-01 · 96 · Number of Included Segments · Required Min 1 Max 10 · Total number of segments included in a transaction set including ST and SE segments

SE-02 · 329 · Transaction Set Control Number · Required Min 4 Max 9 · Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

GE

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

GE-01 · 97 · Number of Transaction Sets Included · Required Min 1 Max 6 · Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02 · 28 · Group Control Number · Required Min 1 Max 9 · Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

IEA-01 · I16 · Number of Included Functional Groups · Required Min 1 Max 5 · A count of the number of functional groups included in an interchange

IEA-02 · I12 · Interchange Control Number · Required Min 9 Max 9 · A control number assigned by the interchange sender

EDI Samples

Sample 1

ISA*00*          *00*          *30*260302465      *30*82-1990296     *230119*0814*^*00501*004443162*0*P*:~
GS*BE*260302465*82-1990296*20230119*0814*230108191*X*005010X220A1~
ST*834*FPH6IXWEM*005010X220A1~
BGN*00*FPH6IXWEM*20230119*081419*CS***4~
N1*IN*SANA BENEFITS, INC.*FI*82-1990296~
N1*P5*SANA BENEFITS, INC.*FI*82-1990296~
N1*TV*SANA BENEFITS, INC.*FI*82-1990296~

INS*Y*18*030*XN*A***FT~
REF*0F*837498753~
REF*1L*10001*Sales~
DTP*336*D8*20180207~
NM1*IL*1*FAKERTON*CHAD****34*837498753~
PER*IP**HP*8767362273~
N3*1200 W STATE ST~
N4*COLUMBUS*OH*43205~
DMG*D8*19871018*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*349*D8*20220131~
REF*1L*11111111-1111-1111-1111-111111111111~

INS*Y*18*030*XN*A***FT~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20120122~
NM1*IL*1*DOOFUS*DAVID*O***34*987378471~
PER*IP**HP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19850807*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*348*D8*20220131~
REF*1L*11111111-1111-1111-1111-333333333333~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*11111111-1111-1111-1111-222222222222~

INS*N*01*030*XN*A~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20190528~
NM1*IL*1*DOOFUS*JENNA****34*233672876~
PER*IP**HP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19890202*F~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*11111111-1111-1111-1111-222222222222~

SE*2487*FPH6IXWEM~
GE*1*230108191~
IEA*1*004443162~