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834 [Oscar] 834 ICHRA – Subscriber Maintenance (FFE v7.0-based) (X220A1)
  • Specification
  • EDI Inspector
todd-test

X12 834 834 [Oscar] 834 ICHRA – Subscriber Maintenance (FFE v7.0-based) (X220A1)

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
EDI sample
  • "Soft term" (member leaves Thatch but stays with Oscar)
View the latest version of this implementation guide as an interactive webpage
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0100
Transaction Set Header
Max use 1
Required
BGN
0200
Beginning Segment
Max use 1
Required
DTP
0400
File Effective Date
Max use 1
Required
Sponsor Name Loop
detail
Member Level Detail Loop
INS
0100
Member Level Detail
Max use 1
Required
REF
0200
Member Supplemental Identifier
Max use 13
Required
REF
0200
Subscriber Identifier
Max use 1
Required
DTP
0250
Member Level Dates
Max use 24
Required
Incorrect Member Name Loop
LS
6880
Loop Header
Max use 1
Required
LE
6885
Loop Trailer
Max use 1
Required
SE
6900
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

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

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

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
String (AN)
Min 10Max 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
Identifier (ID)

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
String (AN)
Min 10Max 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
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 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
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 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
Date (DT)
YYMMDD format

Date of the interchange

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

Time of the interchange

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

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
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

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

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

Code identifying a group of application related transaction sets

BE
Benefit Enrollment and Maintenance (834)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

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

Code identifying party receiving transmission; codes agreed to by trading partners

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

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05
337
Time
Required
Time (TM)
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
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 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
String (AN)

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

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

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

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

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
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • 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.
ST-03
1705
Implementation Convention Reference
Required
String (AN)

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.
Usage notes
  • 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
BGN
0200
Heading > BGN

Beginning Segment

RequiredMax use 1

To indicate the beginning of a transaction set

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

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.

BGN-02
127
Transaction Set Reference Number
Required
String (AN)
Min 1Max 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.
Usage notes
  • 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.
BGN-03
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

  • BGN03 is the transaction set date.
Usage notes
  • This element identifies the date that the submitter created the file.
BGN-04
337
Transaction Set Creation Time
Required
Time (TM)
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.
Usage notes
  • This element is used as a time stamp to uniquely identify the transmission.
BGN-05
623
Time Zone Code
Required
Identifier (ID)

Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow

  • BGN05 is the transaction set time qualifier.
01
Equivalent to ISO P01
02
Equivalent to ISO P02
03
Equivalent to ISO P03
04
Equivalent to ISO P04
05
Equivalent to ISO P05
06
Equivalent to ISO P06
07
Equivalent to ISO P07
08
Equivalent to ISO P08
09
Equivalent to ISO P09
10
Equivalent to ISO P10
11
Equivalent to ISO P11
12
Equivalent to ISO P12
13
Equivalent to ISO M12
14
Equivalent to ISO M11
15
Equivalent to ISO M10
16
Equivalent to ISO M09
17
Equivalent to ISO M08
18
Equivalent to ISO M07
19
Equivalent to ISO M06
20
Equivalent to ISO M05
21
Equivalent to ISO M04
22
Equivalent to ISO M03
23
Equivalent to ISO M02
24
Equivalent to ISO M01
AD
Alaska Daylight Time
AS
Alaska Standard Time
AT
Alaska Time
CD
Central Daylight Time
CS
Central Standard Time
CT
Central Time
ED
Eastern Daylight Time
ES
Eastern Standard Time
ET
Eastern Time
GM
Greenwich Mean Time
HD
Hawaii-Aleutian Daylight Time
HS
Hawaii-Aleutian Standard Time
HT
Hawaii-Aleutian Time
LT
Local Time
MD
Mountain Daylight Time
MS
Mountain Standard Time
MT
Mountain Time
ND
Newfoundland Daylight Time
NS
Newfoundland Standard Time
NT
Newfoundland Time
PD
Pacific Daylight Time
PS
Pacific Standard Time
PT
Pacific Time
TD
Atlantic Daylight Time
TS
Atlantic Standard Time
TT
Atlantic Time
UT
Universal Time Coordinate
BGN-08
306
Action Code
Required
Identifier (ID)

Code indicating type of action

2
Change (Update)

Used to identify a transaction of additions, terminations and changes to the current enrollment.

DTP
0400
Heading > DTP

File Effective Date

RequiredMax use >1

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

Usage notes
  • Required when specified in the contract. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

007
Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Date (DT)
CCYYMMDD format

Expression of a date, a time, or range of dates, times or dates and times

Usage notes

The file effective date.

1000A Sponsor Name Loop
RequiredMax 1
Usage notes

This loop identifies the sponsor. Sponsor Name = Subscriber Name. Identifies the subscriber from the enrollment group.

Variants (all may be used)
Payer LoopTPA/Broker Name Loop
N1
0700
Heading > Sponsor Name Loop > N1

Sponsor Name

RequiredMax use 1

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

Usage notes

This loop identifies the sponsor. Sponsor Name = Subscriber Name. Identifies the subscriber from the enrollment group.

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

Code identifying an organizational entity, a physical location, property or an individual

Usage notes

P5 = Subscriber’s Name

P5
Plan Sponsor
N1-02
93
Plan Sponsor Name
Required
String (AN)
Min 1Max 60

Free-form name

Usage notes

Subscriber’s Name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes

FI = Subscriber’s Social Security Number
94 = Exchange Assigned Subscriber 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 2Max 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.
Usage notes

When N103 = FI, value is Subscriber’s Social Security Number (SSN), if available.

When N103 = 94, value is the Exchange Assigned Subscriber ID.

1000A Sponsor Name Loop end
1000B Payer Loop
RequiredMax 1
Usage notes

This loop identifies the payer. Payer = Insurance Company/Issuer

Variants (all may be used)
Sponsor Name LoopTPA/Broker Name Loop
N1
0700
Heading > Payer Loop > N1

Payer

RequiredMax use 1

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

Usage notes

This loop identifies the payer. Payer = Insurance Company/Issuer

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

Code identifying an organizational entity, a physical location, property or an individual

Usage notes

IN = Issuer Organization Name

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

Free-form name

Usage notes

Issuer Organization Name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes

FI = Issuer Taxpayer ID

FI
Federal Taxpayer's Identification Number
N1-04
67
Insurer Identification Code
Required
String (AN)
Min 2Max 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.
Usage notes

Issuer Taxpayer ID

1000B Payer Loop end
1000C TPA/Broker Name Loop
RequiredMax 1
Usage notes

This loop identifies the Agent or Broker that assisted with enrollment in coverage.

Variants (all may be used)
Sponsor Name LoopPayer Loop
N1
0700
Heading > TPA/Broker Name Loop > N1

TPA/Broker Name

RequiredMax use 1

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

Usage notes

Required when a TPA or a Broker is involved in this enrollment. This loop identifies the Agent or Broker that assisted with enrollment in coverage.

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

Code identifying an organizational entity, a physical location, property or an individual

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

Free-form name

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

Code designating the system/method of code structure used for Identification Code (67)

Usage notes

94 = National Producer Number (NPN)

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 2Max 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.
Usage notes

National Producer Number (NPN)

1000C TPA/Broker Name Loop end
Heading end

Detail

2000 Member Level Detail Loop
RequiredMax 1
INS
0100
Detail > Member Level Detail Loop > INS

Member Level Detail

RequiredMax use 1

To provide benefit information on insured entities

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

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.
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

18
Self
INS-03
875
Maintenance Type Code
Required
Identifier (ID)

Code identifying the specific type of item maintenance

Usage notes

001 is always transmitted with the subscriber.

Exception: a maintenance 834 for a member moving off of Thatch ICHRA but keeping their plan through Oscar. In this case use 022/ZZZ.

001
Change
022
Change in Status
ZZZ
Mutually Defined
INS-04
1203
Maintenance Reason Code
Required
Identifier (ID)

Code identifying the reason for the maintenance change

Usage notes

Null – used to indicate a CSR Variant change (Subscriber only), Financial change (Subscriber only), Demographic Change (affected Subscriber or Non-Subscriber), Agent Broker change (Subscriber only) and No Change (sent with Subscriber or Non-Subscriber when a change does not apply to the individual).
25 used to identify a change to identification elements for a subscriber.
43 used to identify a residential address change.

Exception: a maintenance 834 for a member moving off of Thatch ICHRA but keeping their plan through Oscar. In this case use 86/XT/ZZ.

25
Change in Identifying Data Elements
43
Change of Location
86
Change in Insured Information
XT
Transfer
ZZ
Mutually Defined
INS-05
1216
Benefit Status Code
Required
Identifier (ID)

The type of coverage under which benefits are paid

A
Active
INS-08
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

AC
Active
REF
0200
Detail > Member Level Detail Loop > REF

Member Supplemental Identifier

RequiredMax use 13

To specify identifying information

Usage notes

Exchange Assigned Member ID

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

Code qualifying the Reference Identification

Usage notes

17 = Exchange Assigned Member ID

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.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

Exchange Assigned Member ID

REF
0200
Detail > Member Level Detail Loop > REF

Subscriber Identifier

RequiredMax use 1

To specify identifying information

Usage notes

Exchange Assigned Subscriber ID

Example
Variants (all may be used)
REFMember Supplemental Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes

OF = Exchange Assigned Subscriber ID

0F
Subscriber Number

The assignment of the Subscriber Number is designated within the Insurance Contract.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

Exchange Assigned Subscriber ID

DTP
0250
Detail > Member Level Detail Loop > DTP

Member Level Dates

RequiredMax use 24

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

Usage notes
  • 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.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

Usage notes

303 is only sent with the Subscriber.

303
Maintenance Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Status Information Effective Date
Required
Date (DT)
CCYYMMDD format

Expression of a date, a time, or range of dates, times or dates and times

Usage notes

Maintenance Effective Date

2100A Member Name Loop
RequiredMax 1
NM1
0300
Detail > Member Level Detail Loop > Member Name Loop > NM1

Member Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

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.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Member Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

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

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.

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

Code identifying a party or other code

Usage notes

Member’s SSN

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

Member Communications Numbers

RequiredMax use 1

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

Usage notes
  • 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.
Example
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IP
Insured Party
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

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

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

Usage notes

Email (EM)

EM
Electronic Mail
PER-08
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Member Residence Street Address

RequiredMax use 1

To specify the location of the named party

Usage notes
  • 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.
Example
N3-01
166
Member Address Line 1
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Member Address Line 2
Optional
String (AN)
Min 1Max 55

Address information

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

Member City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Usage notes
  • 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.
Example
N4-01
19
Member City Name
Required
String (AN)
Min 2Max 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
Member State Code
Required
Identifier (ID)
Min 2Max 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
Member Postal Zone or Zip Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Member Demographics

RequiredMax use 1

To supply demographic information

Usage notes
  • 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.
Example
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Member Birth Date
Required
Date (DT)
CCYYMMDD format

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
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
HLH
1300
Detail > Member Level Detail Loop > Member Name Loop > HLH

Member Health Information

RequiredMax use 1

To provide health information

Usage notes
  • 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.
Example
HLH-01
1212
Health Related Code
Required
Identifier (ID)

Code indicating a specific health situation

N
None
T
Tobacco Use
2100A Member Name Loop end
2100B Incorrect Member Name Loop
OptionalMax 1
Usage notes

This loop is only included if there is a change to a specific member demographic element reported in this loop. This loop will contain the original/old value with the updated/new value being reported in the 2100A DMG loop.

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

Member Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
If either Identification Code Qualifier (NM1-08) or Member Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

70
Prior Incorrect Insured
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Member Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

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.

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

Code identifying a party or other code

Usage notes

Original Member SSN – only included if a new SSN is reported in the 2100A Loop.

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

Member Residence Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes

This loop is only included if there is a change to the member's address. This loop will contain the original/old value with the updated/new value being reported in the 2100A N3/N4 loop.

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

Address information

N3-02
166
Member Address Line 2
Optional
String (AN)
Min 1Max 55

Address information

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

Member City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes

This loop is only included if there is a change to the member's address. This loop will contain the original/old value with the updated/new value being reported in the 2100A N3/N4 loop.

Example
N4-01
19
Member City Name
Required
String (AN)
Min 2Max 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
Member State Code
Required
Identifier (ID)
Min 2Max 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
Member Postal Zone or Zip Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Member Demographics

OptionalMax use 1

To supply demographic information

Usage notes

This loop is only included if there is a change to a specific member demographic element reported in this loop. This loop will contain the original/old value with the updated/new value being reported in the 2100A DMG loop.

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

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Member Birth Date
Required
Date (DT)
CCYYMMDD format

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
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
2100B Incorrect Member Name Loop end
2100C Member Mailing Address Loop
OptionalMax 1
Usage notes

Only included if mailing address is different than residence address

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

Individual or Organizational Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

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

Code identifying an organizational entity, a physical location, property or an individual

31
Postal Mailing Address
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
N3
0500
Detail > Member Level Detail Loop > Member Mailing Address Loop > N3

Member Mail Street Address

RequiredMax use 1

To specify the location of the named party

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

Address information

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

Address information

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

Member Mail City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
N4-01
19
Member Mail City Name
Required
String (AN)
Min 2Max 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
Member Mail State Code
Required
Identifier (ID)
Min 2Max 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
Member Mail Postal Zone or ZIP Code
Required
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

2100C Member Mailing Address Loop end
2300 Health Coverage Loop
RequiredMax 99
HD
2600
Detail > Member Level Detail Loop > Health Coverage Loop > HD

Health Coverage

RequiredMax use 1

To provide information on health coverage

Usage notes
  • 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.
Example
HD-01
875
Maintenance Type Code
Required
Identifier (ID)

Code identifying the specific type of item maintenance

Usage notes

001 is always transmitted with the subscriber.

001
Change
HD-03
1205
Insurance Line Code
Required
Identifier (ID)

Code identifying a group of insurance products

DEN
Dental
HLT
Health

Includes both hospital and professional coverage.

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

Health Coverage Dates

RequiredMax use >1

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

Example
Variants (all may be used)
DTPHealth Coverage Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

348
Benefit Begin
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Coverage Period
Required
Date (DT)
CCYYMMDD format

Expression of a date, a time, or range of dates, times or dates and times

Usage notes

Benefit Begin Date

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

Health Coverage Dates

RequiredMax use 6

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

Example
Variants (all may be used)
DTPHealth Coverage Dates
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

303
Maintenance Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Coverage Period
Required
Date (DT)
CCYYMMDD format

Expression of a date, a time, or range of dates, times or dates and times

Usage notes

Maintenance Effective Date

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

Health Coverage Policy Number

RequiredMax use 1

To specify identifying information

Usage notes

Exchange Assigned Policy ID

Example
Variants (all may be used)
REFHealth Coverage Policy Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes

1L = Exchange Assigned Policy ID

1L
Group or Policy Number

Required when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the contract between the sponsor (sender) and payer (receiver); if not required may be sent at the sender's discretion.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

Exchange Assigned Policy ID

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

Health Coverage Policy Number

RequiredMax use 1

To specify identifying information

Usage notes

Plan ID

Example
Variants (all may be used)
REFHealth Coverage Policy Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes

CE = Plan ID

CE
Class of Contract Code
REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

Plan ID

2300 Health Coverage Loop end
LS
6880
Detail > Member Level Detail Loop > LS

Loop Header

RequiredMax use 1

To indicate that the next segment begins a loop

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

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2700 Member Reporting Categories Loop
RequiredMax >1
LX
6881
Detail > Member Level Detail Loop > Member Reporting Categories Loop > LX

Member Reporting Categories

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

Usage notes
  • Use this sequential non-negative integer for LX loops for this member's additional reporting categories.
2750 Reporting Category Loop
OptionalMax 1
Usage notes

ADDL MAINT REASON

Variants (all may be used)
Reporting Category Loop
N1
6882
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

Reporting Category

RequiredMax use 1

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

Usage notes

SEP REASON

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

Code identifying an organizational entity, a physical location, property or an individual

75
Participant
N1-02
93
Member Reporting Category Name
Required
String (AN)

Free-form name

ADDL MAINT REASON
REF
6883
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

Reporting Category Reference

RequiredMax use 1

To specify identifying information

Usage notes
  • Required to specify the reference identifier associated with the reporting category of the member's participating entity.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

17
Client Reporting Category
REF-02
127
Member Reporting Category Reference ID
Required
String (AN)

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

This is the value for ADDL MAINT REASON.
DEMOGRAPHIC CHANGE – Sent with the member being changed.
NO CHANGE – Sent with the any member to whom the change being made does not apply.

DEMOGRAPHIC CHANGE
LEAVE_PLATFORM
NO CHANGE
DTP
6884
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

Reporting Category Date

RequiredMax use 1

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

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

Code specifying type of date or time, or both date and time

007
Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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
Member Reporting Category Effective Date(s)
Required
Date (DT)
CCYYMMDD format

Expression of a date, a time, or range of dates, times or dates and times

2750 Reporting Category Loop end
2750 Reporting Category Loop
OptionalMax 1
Usage notes

REQUEST SUBMIT TIMESTAMP

Variants (all may be used)
Reporting Category Loop
N1
6882
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

Reporting Category

RequiredMax use 1

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

Usage notes

REQUEST SUBMIT TIMESTAMP

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

Code identifying an organizational entity, a physical location, property or an individual

75
Participant
N1-02
93
Member Reporting Category Name
Required
String (AN)

Free-form name

REQUEST SUBMIT TIMESTAMP
REF
6883
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

Reporting Category Reference

RequiredMax use 1

To specify identifying information

Usage notes
  • Required to specify the reference identifier associated with the reporting category of the member's participating entity.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

17
Client Reporting Category
REF-02
127
Member Reporting Category Reference ID
Required
String (AN)
Min 16Max 16
^(?:(?:(?:(?:(?:(?:[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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes

This is the value for REQUEST SUBMIT TIMESTAMP. CCYYMMDDHHMMSSss

2750 Reporting Category Loop end
2700 Member Reporting Categories Loop end
LE
6885
Detail > Member Level Detail Loop > LE

Loop Trailer

RequiredMax use 1

To indicate that the loop immediately preceding this segment is complete

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

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2000 Member Level Detail Loop end
SE
6900
Detail > SE

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)

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

Total number of segments included in a transaction set including ST and SE segments

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

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • 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.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

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

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

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

A count of the number of functional groups included in an interchange

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

A control number assigned by the interchange sender

EDI Samples

"Soft term" (member leaves Thatch but stays with Oscar)

ST*834*74592441*005010X220A1~
BGN*00*74592441*20240105*202953*ET***2~
DTP*007*D8*20240105~
N1*P5*John Doe*FI*999999999~
N1*IN*Oscar*FI*111111111~
N1*BO*Thatch*94*222222222~
INS*Y*18*022*XT*A***AC~
REF*0F*mbr_01hwnmmb6qk1dhj10yaevkcb4k~
REF*17*mbr_01hwnmmb6qk1dhj10yaevkcb4k~
DTP*303*D8*20240105~
NM1*IL*1*Doe*John****34*999999999~
PER*IP**TE*5017622641***EM*john.doe@gmail.com~
N3*101 New Street~
N4*New City*AR*71913~
DMG*D8*19730101*M~
HLH*N~
HD*001**HLT~
DTP*348*D8*20240109~
DTP*303*D8*20240105~
REF*1L*enrlmt_01hwnmmb6qk1dhj10yaevkcb4k~
REF*CE*99999AR020001001~
LS*2700~
LX*1~
N1*75*ADDL MAINT REASON~
REF*17*LEAVE_PLATFORM~
DTP*007*D8*20240105~
LX*2~
N1*75*REQUEST SUBMIT TIMESTAMP~
REF*17*2024121413374163~
LE*2700~
SE*31*74592441~

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