X12 834 [Oscar+Thatch dependent enrollment] (CMS) 834 (FFE to FFE Issuer) Benefit Enrollment and Maintenance (X220A1) v7.0

X12 Release 5010

Delimiters

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

ISA Interchange Control Header

Required · Max use 1

ISA-01 · I01 · Authorization Information Qualifier · Required · Identifier (ID)

• 00: No Authorization Information Present (No Meaningful Information in I02)

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

ISA-03 · I03 · Security Information Qualifier · Required · Identifier (ID)

• 00: No Security Information Present (No Meaningful Information in I04)

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

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

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 · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 2

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 · String (AN) · Min 15 Max 15

ISA-09 · I08 · Interchange Date · Required · Date (DT) · YYMMDD format

ISA-10 · I09 · Interchange Time · Required · Time (TM) · HHMM format

ISA-11 · I65 · Repetition Separator · Required · String (AN) · Min 1 Max 1

• ^: Repetition Separator

ISA-12 · I11 · Interchange Control Version Number · Required · Identifier (ID)

• 00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• BE: Benefit Enrollment and Maintenance (834)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 15

GS-04 · 373 · Date · Required · Date (DT) · CCYYMMDD format

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

GS-06 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

005010X220A1

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 834: Benefit Enrollment and Maintenance

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Implementation Convention Reference · Required · String (AN)

005010X220A1

0200 Heading > BGN

BGN Beginning Segment

Required · Max use 1

BGN-01 · 353 · Transaction Set Purpose Code · Required · Identifier (ID)

• 00: Original

BGN-02 · 127 · Transaction Set Reference Number · Required · String (AN) · Min 1 Max 50

BGN-03 · 373 · Transaction Set Creation Date · Required · Date (DT) · CCYYMMDD format

BGN-04 · 337 · Transaction Set Creation Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

BGN-05 · 623 · Time Zone Code · Required · Identifier (ID)

• 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

BGN-08 · 306 · Action Code · Required · Identifier (ID)

• 2: Change (Update)

0400 Heading > DTP

DTP File Effective Date

Required · Max use >1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 007: Effective
• 303: Maintenance Effective
• 382: Enrollment

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

1000A Sponsor Name Loop Required Max 1

Variants (all may be used)

Payer LoopTPA/Broker Name Loop

0700 Heading > Sponsor Name Loop > N1

N1 Sponsor Name

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• P5: Plan Sponsor

N1-02 · 93 · Plan Sponsor Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 94: Code assigned by the organization that is the ultimate destination of the transaction set
• FI: Federal Taxpayer's Identification Number

N1-04 · 67 · Sponsor Identifier · Required · String (AN) · Min 2 Max 80

1000B Payer Loop Required Max 1

Variants (all may be used)

Sponsor Name LoopTPA/Broker Name Loop

0700 Heading > Payer Loop > N1

N1 Payer

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IN: Insurer

N1-02 · 93 · Insurer Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• FI: Federal Taxpayer's Identification Number

N1-04 · 67 · Insurer Identification Code · Required · String (AN) · Min 2 Max 80

1000C TPA/Broker Name Loop Required Max 2

Variants (all may be used)

Sponsor Name LoopPayer Loop

0700 Heading > TPA/Broker Name Loop > N1

N1 TPA/Broker Name

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• BO: Broker or Sales Office

N1-02 · 93 · TPA or Broker Name · Required · String (AN) · Min 1 Max 60

N1-03 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 94: Code assigned by the organization that is the ultimate destination of the transaction set

N1-04 · 67 · TPA or Broker Identification Code · Required · String (AN) · Min 2 Max 80

Detail

2000 Member Level Detail Loop Required Max >1

0100 Detail > Member Level Detail Loop > INS

INS Member Level Detail

Required · Max use 1

INS-01 · 1073 · Member Indicator · Required · Identifier (ID)

• N: No

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 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
• 24: Dependent of a Minor Dependent
• 25: Ex-spouse
• 26: Guardian
• 31: Court Appointed Guardian
• 38: Collateral Dependent
• 53: Life Partner
• 60: Annuitant
• D2: Trustee
• G8: Other Relationship
• G9: Other Relative

INS-03 · 875 · Maintenance Type Code · Required · Identifier (ID)

• 021: Addition

INS-04 · 1203 · Maintenance Reason Code · Required · Identifier (ID)

• EC: Member Benefit Selection

INS-05 · 1216 · Benefit Status Code · Required · Identifier (ID)

• A: Active

0200 Detail > Member Level Detail Loop > REF

REF Member Supplemental Identifier

Required · Max use 13

Variants (all may be used)

REFSubscriber Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 6O: Cross Reference Number
• 17: Client Reporting Category

REF-02 · 127 · Member Supplemental Identifier · Required · String (AN) · Min 1 Max 50

0200 Detail > Member Level Detail Loop > REF

REF Subscriber Identifier

Required · Max use 1

Variants (all may be used)

REFMember Supplemental Identifier

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0F: Subscriber Number

REF-02 · 127 · Subscriber Identifier · Required · String (AN) · Min 1 Max 50

0250 Detail > Member Level Detail Loop > DTP

DTP Member Level Dates

Required · Max use 24

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 356: Eligibility Begin

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Status Information Effective Date · Required · String (AN) · Min 1 Max 35

2100A Member Name Loop Required Max 1

Variants (all may be used)

Member Mailing Address LoopCustodial Parent LoopResponsible Person Loop

0300 Detail > Member Level Detail Loop > Member Name Loop > NM1

NM1 Member Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Member Last Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Member First Name · Required · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Member Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Member Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 34: Social Security Number

NM1-09 · 67 · Member Identifier · Required · String (AN) · Min 2 Max 80

0400 Detail > Member Level Detail Loop > Member Name Loop > PER

PER Member Communications Numbers

Required · Max use 1

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IP: Insured Party

PER-03 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• TE: Telephone

PER-04 · 364 · Communication Number · Required · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Required · Identifier (ID)

• EM: Electronic Mail

PER-08 · 364 · Communication Number · Required · String (AN) · Min 1 Max 256

0500 Detail > Member Level Detail Loop > Member Name Loop > N3

N3 Member Residence Street Address

Required · Max use 1

N3-01 · 166 · Member Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Member Address Line · Optional · String (AN) · Min 1 Max 55

0600 Detail > Member Level Detail Loop > Member Name Loop > N4

N4 Member City, State, ZIP Code

Required · Max use 1

N4-01 · 19 · Member City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Member State Code · Required · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Member Postal Zone or Zip Code · Required · Identifier (ID) · Min 3 Max 15

0800 Detail > Member Level Detail Loop > Member Name Loop > DMG

DMG Member Demographics

Required · Max use 1

DMG-01 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Member Birth Date · Required · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Gender Code · Required · Identifier (ID)

• F: Female
• M: Male

1300 Detail > Member Level Detail Loop > Member Name Loop > HLH

HLH Member Health Information

Required · Max use 1

HLH-01 · 1212 · Health Related Code · Required · Identifier (ID)

• N: None
• T: Tobacco Use

2100C Member Mailing Address Loop Optional Max 1

Variants (all may be used)

Member Name LoopCustodial Parent LoopResponsible Person Loop

0300 Detail > Member Level Detail Loop > Member Mailing Address Loop > NM1

NM1 Member Mailing Address

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 31: Postal Mailing Address

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

0500 Detail > Member Level Detail Loop > Member Mailing Address Loop > N3

N3 Member Mail Street Address

Required · Max use 1

N3-01 · 166 · Member Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Member Address Line · Optional · String (AN) · Min 1 Max 55

0600 Detail > Member Level Detail Loop > Member Mailing Address Loop > N4

N4 Member Mail City, State, ZIP Code

Required · Max use 1

N4-01 · 19 · Member Mail City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Member Mail State Code · Required · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Member Mail Postal Zone or ZIP Code · Required · Identifier (ID) · Min 3 Max 15

2100F Custodial Parent Loop Optional Max 1

Variants (all may be used)

Member Name LoopMember Mailing Address LoopResponsible Person Loop

0300 Detail > Member Level Detail Loop > Custodial Parent Loop > NM1

NM1 Custodial Parent

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• S3: Custodial Parent

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Custodial Parent Last Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Custodial Parent First Name · Required · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Custodial Parent Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Custodial Parent Name Suffix · Optional · String (AN) · Min 1 Max 10

0500 Detail > Member Level Detail Loop > Custodial Parent Loop > N3

N3 Custodial Parent Street Address

Required · Max use 1

N3-01 · 166 · Custodial Parent Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Custodial Parent Address Line · Optional · String (AN) · Min 1 Max 55

0600 Detail > Member Level Detail Loop > Custodial Parent Loop > N4

N4 Custodial Parent City, State, ZIP Code

Required · Max use 1

N4-01 · 19 · Custodial Parent City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Custodial Parent State Code · Required · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Custodial Parent Postal Zone or ZIP Code · Required · Identifier (ID) · Min 3 Max 15

2100G Responsible Person Loop Optional Max 13

Variants (all may be used)

Member Name LoopMember Mailing Address LoopCustodial Parent Loop

0300 Detail > Member Level Detail Loop > Responsible Person Loop > NM1

NM1 Responsible Person

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• S1: Parent

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Responsible Party Last or Organization Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Responsible Party First Name · Required · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Responsible Party Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Responsible Party Suffix Name · Optional · String (AN) · Min 1 Max 10

0500 Detail > Member Level Detail Loop > Responsible Person Loop > N3

N3 Responsible Person Street Address

Required · Max use 1

N3-01 · 166 · Responsible Party Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Responsible Party Address Line · Optional · String (AN) · Min 1 Max 55

0600 Detail > Member Level Detail Loop > Responsible Person Loop > N4

N4 Responsible Person City, State, ZIP Code

Required · Max use 1

N4-01 · 19 · Responsible Person City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Responsible Person State Code · Required · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Responsible Person Postal Zone or ZIP Code · Required · Identifier (ID) · Min 3 Max 15

2300 Health Coverage Loop Required Max 99

2600 Detail > Member Level Detail Loop > Health Coverage Loop > HD

HD Health Coverage

Required · Max use 1

HD-01 · 875 · Maintenance Type Code · Required · Identifier (ID)

• 021: Addition

HD-03 · 1205 · Insurance Line Code · Required · Identifier (ID)

• DEN: Dental
• HLT: Health

2700 Detail > Member Level Detail Loop > Health Coverage Loop > DTP

DTP Health Coverage Dates

Required · Max use 6

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 348: Benefit Begin

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Coverage Period · Required · String (AN) · Min 1 Max 35

2900 Detail > Member Level Detail Loop > Health Coverage Loop > REF

REF Health Coverage Policy Number

Required · Max use 1

Variants (all may be used)

REFHealth Coverage Policy Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number

REF-02 · 127 · Member Group or Policy Number · Required · String (AN) · Min 1 Max 50

2900 Detail > Member Level Detail Loop > Health Coverage Loop > REF

REF Health Coverage Policy Number

Required · Max use 14

Variants (all may be used)

REFHealth Coverage Policy Number

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• CE: Class of Contract Code

REF-02 · 127 · Member Group or Policy Number · Required · String (AN) · Min 1 Max 50

6880 Detail > Member Level Detail Loop > LS

LS Loop Header

Required · Max use 1

LS-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

2700 Member Reporting Categories Loop Required Max >1

6881 Detail > Member Level Detail Loop > Member Reporting Categories Loop > LX

LX Member Reporting Categories

Required · Max use 1

LX-01 · 554 · Assigned Number · Required · Numeric (N0) · Min 1 Max 6

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category LoopReporting Category Loop

6882 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

N1 Reporting Category

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 75: Participant

N1-02 · 93 · Member Reporting Category Name · Required · String (AN)

PRE AMT TOT

6883 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

REF Reporting Category Reference

Required · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 9X: Account Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN) · Min 1 Max 50

6884 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

DTP Reporting Category Date

Required · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 007: Effective

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Member Reporting Category Effective Date(s) · Required · String (AN) · Min 1 Max 35

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category LoopReporting Category Loop

6882 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

N1 Reporting Category

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 75: Participant

N1-02 · 93 · Member Reporting Category Name · Required · String (AN)

REQUEST SUBMIT TIMESTAMP

6883 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

REF Reporting Category Reference

Required · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 17: Client Reporting Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN) · Min 1 Max 50 · ^(?:(?:(?:(?:(?:(?:[1-9]\d{3})|(?:0[1-9]\d{2})))(?:(?:(?:0[1-9]|1[0-2])(?:0[1-9]|1\d|2[0-8]))|(?:(?:0[13-9]|1[0-2])(?:29|30))|(?:(?:0[13578]|1[02])31)))(?:(?:[01]\d|2[0-3])(?:[0-5]\d)(?:[0-5]\d)(?:[0-9]{2})))|(?:(?:(?:(?:[1-9]\d(?:[02468][048]|[13579][26]))|(?:0[1-9]\d(?:[02468][048]|[13579][26])))0229)(?:(?:[01]\d|2[0-3])(?:[0-5]\d)(?:[0-5]\d)(?:[0-9]{2}))))$ RegEx pattern

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category LoopReporting Category Loop

6882 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

N1 Reporting Category

Required · Max use 1

N1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 75: Participant

N1-02 · 93 · Member Reporting Category Name · Required · String (AN)

SEP REASON

6883 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

REF Reporting Category Reference

Required · Max use 1

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 17: Client Reporting Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN)

• 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)

6884 Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

DTP Reporting Category Date

Required · Max use 1

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 007: Effective

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Member Reporting Category Effective Date(s) · Required · String (AN) · Min 1 Max 35

6885 Detail > Member Level Detail Loop > LE

LE Loop Trailer

Required · Max use 1

LE-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

6900 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Dependent sample

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240105*1802*^*00501*000001566*1*P*>~
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~