X12 834 [Oscar+Thatch dependent enrollment] (CMS) 834 (FFE to FFE Issuer) Benefit Enrollment and Maintenance (X220A1) v7.0
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
00*
*
00*
*
XX*
XXXXXXXXXXXXXXX*
XX*
XXXXXXXXXXXXXXX*
251116*
2122*
^*
00501*
000000000*
X*
X*
>~
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
Date of the interchange
Time of the interchange
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
BE*
XXXXXXX*
XXX*
20251116*
1049*
0*
X*
005010X220A1~
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
834*
0001*
005010X220A1~
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
00*
XXX*
20251116*
1439*
16***
2~
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.
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.
The Federal platform is in the Eastern Time Zone. FFE Issuers within the same time zone do not need to transmit this data element
- 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
Code indicating type of action
- 2
- Change (Update)
Used to identify a transaction of additions, terminations and changes to the current enrollment.
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.
382*
D8*
XXXXX~
Code specifying type of date or time, or both date and time
- 007
- Effective
- 303
- Maintenance Effective
- 382
- Enrollment
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
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.
P5*
XX*
FI*
XXXXXXX~
Code identifying an organizational entity, a physical location, property or an individual
- P5
- Plan Sponsor
Free-form name
Subscriber’s Name
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
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.
When N103 = FI, value is Subscriber’s Social Security Number (SSN), if available
When N103 = 94, value is the Exchange Assigned Subscriber ID
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.
IN*
XXXXXX*
FI*
XXXXXX~
Code identifying an organizational entity, a physical location, property or an individual
- IN
- Insurer
Free-form name
Issuer Organization Name
Code designating the system/method of code structure used for Identification Code (67)
- 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.
Issuer Taxpayer ID
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.
BO*
X*
94*
XX~
Code identifying an organizational entity, a physical location, property or an individual
- BO
- Broker or Sales Office
Free-form name
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
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.
National Producer Number (NPN)
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.
N*
16*
021*
EC*
A~
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
Code indicating the relationship between two individuals or entities
- For dependents, this value identifies their relationship to the subscriber. For example, a daughter would be value 19.
When INS01 = N, the value identifies the relationship to the subscriber.
- 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
- 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
- 021
- Addition
Use this code to add a subscriber or dependent.
Code identifying the reason for the maintenance change
- 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.
The type of coverage under which benefits are paid
- A
- Active
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.
6O*
X~
Code qualifying the Reference Identification
17 – Always sent
6O – Included, If available
- 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.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
When REF01 = 17, the value is Exchange Assigned Member ID
When REF01 = 6O, the value is Payment Transaction ID
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.
0F*
XXXXXX~
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
Exchange Assigned Subscriber ID
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.
356*
D8*
X~
Code specifying type of date or time, or both date and time
- 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.
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
Eligibility Begin Date
Member Name
To supply the full name of an individual or organizational entity
IL*
1*
XXXXX*
XXXXXX*
XXXXXX**
XXXXXX*
34*
XXXX~
Code identifying an organizational entity, a physical location, property or an individual
- 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
Individual last name or organizational name
Individual first name
Individual middle name or initial
Suffix to individual 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.
Code identifying a party or other code
Member’s SSN
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.
IP**
TE*
X***
EM*
XXX~
Code identifying the major duty or responsibility of the person or group named
- IP
- Insured Party
Code identifying the type of communication number
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
Email (EM)
- EM
- Electronic Mail
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.
XX*
XX~
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.
XX*
XX*
XXX~
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)
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.
D8*
XXXXXX*
M~
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
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.
T~
Code indicating a specific health situation
- N
- None
- T
- Tobacco Use
Only included if mailing address is different than residence address
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.
31*
1~
Member Mail Street Address
To specify the location of the named party
XXXX*
X~
Member Mail City, State, ZIP Code
To specify the geographic place of the named party
XXXX*
XX*
XXX~
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)
Only included if Subscriber is under 18 and if provided on application.
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.
S3*
1*
XXXX*
XXXX*
XX**
XXXXXX~
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 first name
Individual middle name or initial
Suffix to individual name
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.
XXXXXX*
XX~
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.
XXX*
XX*
XXXX~
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)
Only sent if the Subscriber is younger than 18 and the RP is different than the Custodial Parent information provided on the application
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.
S1*
1*
XXXXXX*
XXX*
XXXXXX**
X~
Code identifying an organizational entity, a physical location, property or an individual
- S1
- Parent
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual first name
Individual middle name or initial
Suffix to individual name
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.
XXXXXX*
XXXX~
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.
XXXXXXX*
XX*
XXX~
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)
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.
021**
DEN~
Code identifying the specific type of item maintenance
- Required to identify the specific type of item maintenance.
- 021
- Addition
Code identifying a group of insurance products
- DEN
- Dental
- HLT
- Health
Includes both hospital and professional coverage.
Health Coverage Dates
To specify any or all of a date, a time, or a time period
348*
D8*
XXXX~
Code specifying type of date or time, or both date and time
- 348
- Benefit Begin
This is the effective date of coverage. This code must always be sent when adding or reinstating coverage.
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
Benefit Begin Date
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.
1L*
XXXXX~
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
When REF01 = 1L, the value is the Exchange Assigned Policy ID
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.
CE*
XXXXX~
Code qualifying the Reference Identification
- CE
- Class of Contract Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
When REF01 = CE, the value is the 16-digit plan ID
Loop Header
To indicate that the next segment begins a loop
2700~
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.
000000~
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.
75*
PRE AMT TOT~
Reporting Category Reference
To specify identifying information
- Required to specify the reference identifier associated with the reporting category of the member's participating entity.
9X*
XXXXX~
Code qualifying the Reference Identification
- 9X
- Account Category
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
007*
D8*
XX~
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
Expression of a date, a time, or range of dates, times or dates and times
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.
75*
REQUEST SUBMIT TIMESTAMP~
Reporting Category Reference
To specify identifying information
- Required to specify the reference identifier associated with the reporting category of the member's participating entity.
17*
1120022903145148~
Code qualifying the Reference Identification
- 17
- Client Reporting Category
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
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.
75*
SEP REASON~
Reporting Category Reference
To specify identifying information
- Required to specify the reference identifier associated with the reporting category of the member's participating entity.
17*
32~
Code qualifying the Reference Identification
- 17
- Client Reporting Category
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- 02
- Addition of individual due to birth
- 05
- Addition of individual due to adoption
- 07
- Loss of Minimum Essential Coverage (MEC) or denied Medicaid or CHIP
- 32
- Addition of individual due to marriage
- 43
- New QHPs available due to a permanent move
- FC
- Change to Financial Information (APTC or CSR)
- HR
- Individual is newly eligible for an Individual Coverage Health Reimbursement Arrangement (ICHRA)
- NE
- Individual is released from incarceration, gains lawful presence status, or is a member of a federally recognized American Indian tribe or an Alaskan native
- QS
- Individual is newly eligible for a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
Reporting Category Date
To specify any or all of a date, a time, or a time period
007*
D8*
XXXX~
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
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
2700~
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)
000000*
0001~
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
000*
000~
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
00*
000000000~
Dependent sample
GS*BE*SENDER*RECEIVER*20240105*1802*000005757*X*005010X220A1~
ST*834*0000001*005010X220A1~
BGN*00*74592441*20240105*202953*ET***2~
DTP*007*D8*20240101~
N1*P5*John Doe*FI*0000000001~
N1*IN*Oscar*FI*111111111~
N1*BO*Thatch*94*111111111~
INS*N*19*021*EC*A**~
REF*0F*0000068929~
REF*17*0000068929~
DTP*356*D8*20240101~
NM1*IL*1*Doe*Jane****34*000000000~
PER*IP**TE*5017622641***EM*jane.doe@example.com~
N3*106 Test Trail~
N4*Hot Springs*AR*71913~
DMG*D8*20030101*F~
HLH*N~
HD*021**HLT~
DTP*348*D8*20240101~
REF*1L*68929001~
REF*CE*99999AR020001001~
LS*2700~
LX*1~
N1*75*REQUEST SUBMIT TIMESTAMP~
REF*17*2023121413374163~
LX*2~
N1*75*SEP REASON~
REF*17*HR~
DTP*007*D8*20240101~
LX*3~
N1*75*PRE AMT TOT~
REF*9X*941.20~
DTP*007*D8*20240101~
LE*2700~
SE*34*0000001~
GE*1*000005757~
IEA*1*000001566~
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