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EDI 834 X307 - Health Insurance Exchange: Enrollment

Functional Group BE

X12N Insurance Subcommittee

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.

What is an EDI 834?

An EDI 834 Benefit Enrollment and Maintenance is sent from employers to insurance providers to communicate health insurance details about employees. It contains information about the sponsor and the insurance company (N1 segment), the person to be enrolled (NM1 segment), and eligibility / benefit information (HD segment). It must be HIPAA 00510 compliant.

How is an EDI 834 used?

For example, an Employer A submits an EDI 834 Benefit Enrollment and Maintenance to Insurance Provider B to enroll a new employee into the corporate health care plan.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 0200 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 0300 · REF · Exchange Assigned Qualified Health Plan Identifier · Max 1 · Optional

   To specify identifying information

   Traditionally, this identifier represents a combination of the plan/product selected and the employer. In this implementation, the QHP identifier is the same for all employer groups within the SHOP market.
   Required when all enrollees within this transaction apply to a single QHP. If not required by this implementation guide, do not send.

4. 0300 · REF · Issuer Assigned Qualified Health Plan Identifier · Max 1 · Optional

   To specify identifying information

   Required when all enrollees within this transaction apply to a single QHP, the issuer has assigned an identifier to that QHP, and the identifier is known to the submitter. If not required by this implementation guide, do not send.
   Traditionally, this identifier represents a combination of the plan/product selected and the employer. In this implementation, the QHP identifier is the same for all employer groups within the SHOP market.
   The QHP identified at this level may be overridden at the enrollee level when necessary.

5. 0300 · REF · Exchange Assigned Employer Group Identifier · Max 1 · Optional

   To specify identifying information

   Required when the enrollment is from a SHOP exchange and all enrollees within this transaction apply to a single employer group. If not required by this implementation guide, do not send.

6. 0300 · REF · Issuer Assigned Employer Group Identifier · Max 1 · Optional

   To specify identifying information

   Required when: all enrollees within this transaction apply to a single employer group, the issuer has assigned an identifier to that employer group, and the identifier is known to the submitter. If not required by this implementation guide, do not send.

7. 0400 · DTP · File Effective Date · Max 1 · Mandatory

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

   The Effective Date reported at this level applies to all records within the transaction unless overridden at the enrollee level.
   The date by which all records in the file are effective unless overridden by a Member Level date.

8. 0600 · QTY · Transaction Set Control Totals · Max 1 · Mandatory

   To specify quantity information

   The Transaction Set Totals for Dependents and Subscribers reported in QTY segments at this level must add up to the Total reported in this segment.
   The Transaction Set Total is a sum of all INS segments included in this transaction (ST/SE).

9. 0600 · QTY · Dependent Record Count · Max 1 · Optional

   To specify quantity information

   Required when this transaction contains records for dependents. If not required by this implementation guide, do not send.
   The number of dependent records equals the number of instances of loop 2000 where INS01 = N.

10. 0600 · QTY · Subscriber Record Count · Max 1 · Optional

    To specify quantity information

    Required when this transaction contains subscriber records. If not required by this implementation guide, do not send.
    The number of subscriber records equals the number of instances of loop 2000 where INS01 = Y.

11. 1000A Loop Mandatory Repeat 1

    1. 0700 · N1 · Submitter Name · Max 1 · Mandatory

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

12. 1000B Loop Mandatory Repeat 1

    1. 0700 · N1 · Receiver Name · Max 1 · Mandatory

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

13. 1000C Loop Mandatory Repeat 1

    1. 0700 · N1 · QHP Issuer · Max 1 · Mandatory

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

14. 1000D Loop Optional Repeat 1

    1. 0700 · N1 · Sponsor Name · Max 1 · Mandatory

       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.
       SHOP related transactions will identify the employer as the sponsor.
       Required when this transaction (ST/SE) contains SHOP enrollments only, and all enrollees share the same sponsor. If not required by this implementation guide, do not send.

15. 1000E Loop Optional Repeat >1

    1. 0700 · N1 · Sponsor/Employer Group Setup - Name · Max 1 · Mandatory

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

       Required when this transaction (ST/SE) contains an initial enrollment for a Sponsor/Employer Group or when the Sponsor's/Employer Group's information is being updated. If not required by this implementation guide, do not send.
       In this context, initial enrollment means the first time an exchange presents an employer group to an issuer.
       When this loop is used, it is preferred this transaction (ST/SE) be limited to enrollees that are part of this employer group. If this option is not selected, the design and intent is issuers will be able to know which enrollees are linked to this employer group using the Exchange Assigned Employer Group Identifier reported in this loop to the Exchange Assigned Employer Group Identifier reported in Loop 2000.

    2. 0900 · N3 · Primary Billing Address · Max 1 · Mandatory

       To specify the location of the named party

    3. 1000 · N4 · Primary Billing City, State, ZIP Code · Max 1 · Mandatory

       To specify the geographic place of the named party

    4. 1100 · PER · Primary Contact Information · Max 1 · Mandatory

       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).

    5. 1100 · PER · Alternate Contact Information · Max 1 · Optional

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

       Required when there is an alternate contact for the Employer Group/ Sponsor. If not required by this implementation guide, do not send.
       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).

    6. 1100EA Loop Mandatory Repeat 1

       1. 1200 · ACT · Sponsor/Employer Group Information · Max 1 · Mandatory

          To specify account information

       2. 1300 · REF · Exchange Assigned Employer Group Identifier · Max 1 · Mandatory

          To specify identifying information

       3. 1300 · REF · Employer Size · Max 1 · Mandatory

          To specify identifying information

       4. 1300 · REF · Employer Classification · Max 1 · Mandatory

          To specify identifying information

       5. 1300 · REF · Employer Dependent Information · Max 1 · Optional

          To specify identifying information

          Required when dependent coverage is offered by this Sponsor/Employer Group. If not required by this implementation guide, do not send.

       6. 1400 · N3 · Alternate Billing Address · Max 1 · Optional

          To specify the location of the named party

          Required when there is an alternate billing address. If not required by this implementation guide, do not send.

       7. 1500 · N4 · Alternate Billing City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when there is an alternate billing address. If not required by this implementation guide, do not send.

       8. 1600 · PER · Alternate Billing Contact Information · Max 1 · Optional

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

          Required when there is an alternate billing contact. If not required by this implementation guide, do not send.
          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).

       9. 1700 · DTP · Employer Waiting Period · Max 1 · Mandatory

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

       10. 1800 · AMT · Employer Contribution · Max 1 · Mandatory

           To indicate the total monetary amount

    7. 1100EB Loop Optional Repeat 9

       1. 1200 · ACT · Sponsor/Employer Group Other Location Information · Max 1 · Mandatory

          To specify account information

          Required when there are additional locations for this Sponsor/Employer Group. If not required by this implementation guide, do not send.

       2. 1400 · N3 · Sponsor/Employer Group Other Location Street Address · Max 1 · Mandatory

          To specify the location of the named party

       3. 1500 · N4 · Sponsor/Employer Group Other Location City, State, ZIP Code · Max 1 · Mandatory

          To specify the geographic place of the named party

       4. 1600 · PER · Sponsor/Employer Group Other Location Contact Information · Max 1 · Optional

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

          Required when there is contact information specific to this other location. If not required by this implementation guide, do not send.
          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).

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 0100 · INS · Enrollee Level Detail · Max 1 · Mandatory

      To provide benefit information on insured entities

      Subscriber information must precede dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.

   2. 0200 · REF · Exchange Assigned Qualified Health Plan Identifier · Max 1 · Optional

      To specify identifying information

      Required when the Exchange Assigned QHP segment in the header is not used. If not required by this implementation guide, do not send.
      The QHP identified by this segment may be overwritten by a coverage specific identifier when necessary.

   3. 0200 · REF · Issuer Assigned Qualified Health Plan Identifier · Max 1 · Optional

      To specify identifying information

      Required when the Issuer Assigned QHP segment in the header is not used, and the Issuer Assigned QHP Identifier is known by the submitter. If not required by this implementation guide, do not send.
      The QHP identified by this segment may be overwritten by a coverage specific identifier when necessary.

   4. 0200 · REF · Coverage Specific Exchange Assigned Qualified Health Plan Identifier · Max 1 · Optional

      To specify identifying information

      Required when one or more of the specific coverages identified in Loop ID 2300 belong to a different QHP than reported as the enrollee or header level QHP. If not required by this implementation guide, do not send.
      The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

   5. 0200 · REF · Coverage Specific Issuer Assigned Qualified Health Plan Identifier · Max 1 · Optional

      To specify identifying information

      Required when one or more of the specific coverages identified in Loop ID 2300 belong to a different QHP than reported as the enrollee or header level QHP and the Issuer Assigned QHP identifier is known to the submitter. If not required by this implementation guide, do not send.
      The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

   6. 0200 · REF · Exchange Assigned Employer Group Identifier · Max 1 · Optional

      To specify identifying information

      Required when the enrollment is from a SHOP exchange and the header exchange assigned employer group segment is not used. If not required by this implementation guide, do not send.
      The Employer Group identified by this segment may be overwritten by a coverage specific identifier when necessary.

   7. 0200 · REF · Issuer Assigned Employer Group Identifier · Max 1 · Optional

      To specify identifying information

      Required when: the enrollment is from a SHOP exchange, the header issuer assigned employer group segment is not used, the issuer has assigned an identifier to that employer group, and the identifier is known to the submitter. If not required by this implementation guide, do not send.
      The Employer Group identified by this segment may be overwritten by a coverage specific identifier when necessary.

   8. 0200 · REF · Coverage Specific Exchange Assigned Employer Group Identifier · Max 1 · Optional

      To specify identifying information

      Required when the enrollment is from a SHOP exchange and one or more of the specific coverages identified in Loop ID 2300 belong to a different employer group than reported as either the enrollee or header level employer group. If not required by this implementation guide, do not send.
      The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

   9. 0200 · REF · Coverage Specific Issuer Assigned Employer Group Identifier · Max 1 · Optional

      To specify identifying information

      Required when the enrollment is from a SHOP exchange, and one or more of the specific coverages identified in Loop ID 2300 belong to a different employer group than reported as either the enrollee or header level employer group, and the issuer assigned identifier is known by the submitter. If not required by this implementation guide, do not send.
      The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

   10. 0200 · REF · Exchange Assigned Policy Identifier · Max 1 · Mandatory

       To specify identifying information

       For the purposes of this implementation, policy is defined as the collective of enrollees constituting a family unit or household.

   11. 0200 · REF · Issuer Assigned Policy Identifier · Max 1 · Optional

       To specify identifying information

       Required when known by the submitter. If not required by this implementation guide, do not send.

   12. 0200 · REF · Exchange Assigned Subscriber Identifier · Max 1 · Mandatory

       To specify identifying information

       This segment must contain the unique subscriber identification number assigned by the Health Insurance Exchange. This identifier may be used to link the dependent to the subscriber.

   13. 0200 · REF · Issuer Assigned Subscriber Identifier · Max 1 · Optional

       To specify identifying information

       Required when the issuer has assigned an identifier to the subscriber and that identifier has been made known to the submitter. If not required by this implementation guide, do not send.
       This segment must contain the unique SUBSCRIBER identification;number assigned by the issuer. This identifier may be used to link the subscriber to the dependents.

   14. 0200 · REF · Exchange Assigned Dependent Identifier · Max 1 · Optional

       To specify identifying information

       Required when: an exchange has assigned an identifier to the dependent named in Loop 2100A, and that identifier is known to the submitter, and the identifier is permitted for use under applicable regulation. If not required by this implementation guide, do not send.
       This segment must contain the unique identifier assigned by the Health Insurance Exchange.

   15. 0200 · REF · Issuer Assigned Dependent Identifier · Max 1 · Optional

       To specify identifying information

       Required when the issuer has assigned an identifier to the dependent and that identifier has been made known to the submitter. If not required by this implementation guide, do not send.
       This segment must contain the unique identifier assigned by the Issuer.

   16. 0200 · REF · Exchange Assigned APTC Contributor/Tax Payer Identifier · Max 1 · Optional

       To specify identifying information

       Required when: - an exchange has assigned an identifier to the ATPC contributor named in Loop 2100I, - and the identifier is known to the submitter, - and the identifier is permitted for use under applicable regulation. If not required by this implementation guide, do not send.

   17. 0200 · REF · Issuer Assigned APTC Contributor/Tax Payer Identifier · Max 1 · Optional

       To specify identifying information

       Required when the issuer has assigned an identifier to the individual named in Loop 2100I and that identifier is known to the submitter. If not required by this implementation guide, do not send.

   18. 0200 · REF · Enrollee Supplemental Identifier · Max 2 · Optional

       To specify identifying information

       Required when sending additional identifying information on the enrollee. If not required by this implementation guide, do not send.

   19. 0200 · REF · ACH Bank Information · Max 1 · Optional

       To specify identifying information

       Required when an exchange has collected bank information for the purposes of premium payment. If not required by this implementation guide, do not send.

   20. 0200 · REF · Credit/Debit Card Information · Max 1 · Optional

       To specify identifying information

       Required when an exchange has collected credit/debit card information for the purposes of premium payment. If not required by this implementation guide, do not send.

   21. 0250 · DTP · Enrollee Level Dates · Max 18 · Optional

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

       Required when any of the dates defined by the date qualifiers and code notes available in DTP01 apply to the enrollee initial enrollment and/or enrollment reconciliation process. OR Required when this transaction is reporting a change to an enrollee's record, and one of the dates defined by the date qualifiers and code notes available in DTP01 have changed. 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 an Enrollee 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.
       For new enrollments or reconciliation, all dates that apply to the particular insurance contract are to be sent.
       For updates, all dates that apply to the particular insurance contract which have changed are to be sent.

   22. 0250 · DTP · Indian Tribal Status Effective Date · Max 1 · Optional

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

       Required when collected by an exchange. If not required by this implementation guide, do not send.

   23. 0250 · DTP · Tobacco Status Effective Date · Max 1 · Optional

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

       Required when collected by an exchange. If not required by this implementation guide, do not send.

   24. 0250 · DTP · Credit Card Expiration Date · Max 1 · Optional

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

       Required when an exchange has collected credit/debit card information for the purposes of premium payment. If not required by this implementation guide, do not send.

   25. 2100A Loop Mandatory Repeat 1

       1. 0300 · NM1 · Enrollee Name · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

       2. 0400 · PER · Enrollee Communications Numbers · Max 1 · Optional

          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 new subscribers) or (when enrolling new dependents with contact information different than the subscriber) or (when changing the member's contact information)) and the information is available to the submitter. If not required by this implementation guide, do not send.
          The transaction is limited to 1 iteration of the PER segment at this level. As a result, the developers of this transaction have established a primary, secondary and tertiary priority for contact information. When more than three communication methods are collected, the exchange will give the following methods priority. 1. Primary Phone 2. Secondary Phone 3. Preferred communication method If one or more of the listed methods is not collected, any of the others may be used.

       3. 0500 · N3 · Enrollee Residence Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when enrolling new subscribers, when enrolling new dependents with address different than the subscriber, or when changing a member's address. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Enrollee City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when enrolling new subscribers, when enrolling new dependents with address different than the subscriber, or when changing a member's address. If not required by this implementation guide, do not send.

       5. 0800 · DMG · Enrollee Demographics · Max 1 · Optional

          To supply demographic information

          Required when enrolling a new enrollee, changing an enrollee's demographic information, or terminating an enrollee. If not required by this implementation guide, do not send.

       6. 1000 · EC · Employment Class · Max >1 · Optional

          To provide class of employment information

          Required when sending additional employment class information on the enrollee. If not required by this implementation guide, do not send.

       7. 1300 · HLH · Enrollee Health Information · Max 1 · Optional

          To provide health information

          Required on initial enrollment of an enrollee when appropriate medical information about the enrollee is available. If not required by this implementation guide, do not send.

       8. 1400 · HI · Enrollment Amount Information · Max 10 · Optional

          To supply information related to the delivery of health care

          Required when there are amounts that apply to the individual identified in this loop. If not required by this implementation guide, do not send.
          Examples of amounts to be reported include: APTCs, CSRs, APTC Amount Paid, Total Premium Amount (APTC + Enrollee Premium Liability), State Mandated Benefit Amount, and others.

       9. 1500 · LUI · Enrollee Language · Max >1 · Optional

          To specify language, type of usage, and proficiency or fluency

          Required when an Exchange has collected this information, is legally allowed to share it, and the enrollee's primary language is not English. If not required by this implementation guide do not send.

   26. 2100B Loop Optional Repeat 1

       1. 0300 · NM1 · Incorrect Enrollee Name · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If not required by this implementation guide, do not send.

       2. 0800 · DMG · Incorrect Enrollee Demographics · Max 1 · Optional

          To supply demographic information

          Required when the 2100A loop DMG segment contains corrected demographic information. If not required by this implementation guide, do not send.

   27. 2100C Loop Optional Repeat 1

       1. 0300 · NM1 · Enrollee Mailing Address · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when the enrollee 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.

       2. 0500 · N3 · Enrollee Mail Street Address · Max 1 · Mandatory

          To specify the location of the named party

       3. 0600 · N4 · Enrollee Mail City, State, ZIP Code · Max 1 · Mandatory

          To specify the geographic place of the named party

   28. 2100D Loop Optional Repeat 3

       1. 0300 · NM1 · Enrollee Employer · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop.
          Required when the enrollee is employed by someone other than the sponsor and the employer is known to the submitter. If not required by this implementation guide, do not send.

       2. 0400 · PER · Enrollee Employer Communications Numbers · Max 1 · Optional

          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 an Exchange has collected the information, the enrollee is employed by someone other than the sponsor, and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Enrollee Employer Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when an Exchange has collected the information, the enrollee is employed by someone other than the sponsor, and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Enrollee Employer City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when an Exchange has collected the information, the enrollee is employed by someone other than the sponsor, and the Exchange can legally share the information. If not required by this implementation guide, do not send.

   29. 2100E Loop Optional Repeat 1

       1. 0300 · NM1 · Custodial Parent · Max 1 · Mandatory

          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.

       2. 0400 · PER · Custodial Parent Communications Numbers · Max 1 · Optional

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

          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
          Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the Exchange. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Custodial Parent Street Address · Max 1 · Optional

          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 Exchange. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Custodial Parent City, State, ZIP Code · Max 1 · Optional

          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 Exchange. If not required by this implementation guide, do not send.

   30. 2100F Loop Optional Repeat 13

       1. 0300 · NM1 · Responsible Person · Max 1 · Mandatory

          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 enrollee. If not required by this implementation guide, do not send.
          This segment does not identify the individual with fiscal responsibility for premium payment. That person or entity is identified as the sponsor.

       2. 0400 · PER · Responsible Person Communications Numbers · Max 1 · Optional

          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 an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Responsible Person Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Responsible Person City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

   31. 2100G Loop Optional Repeat 1

       1. 0300 · NM1 · Drop Off Location · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when enrollee has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.

       2. 0500 · N3 · Drop Off Location Street Address · Max 1 · Mandatory

          To specify the location of the named party

       3. 0600 · N4 · Drop Off Location City, State, ZIP Code · Max 1 · Mandatory

          To specify the geographic place of the named party

   32. 2100H Loop Optional Repeat 1

       1. 0300 · NM1 · Sponsor Name · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when Loop 1000D Sponsor is not used AND: this enrollment is from a SHOP exchange. OR the enrollment is from an Individual Market Exchange, and the exchange is able to determine the entity responsible for payment. If not required by this implementation guide, do not send.
          When the exchange cannot determine a sponsor (the entity responsible for premium payment) in the individual market, the contact person must be reported in the subscriber PER.
          This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.

   33. 2100I Loop Optional Repeat 1

       1. 0300 · NM1 · APTC Contributor/Tax Payer Name · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when an APTC amount designated for this policy is attributed to a tax payer who is not an enrollee in this policy and the exchange provides APTC tax payer detail. If not required by this implementation guide, do not send.

       2. 0400 · PER · APTC Contributor/Tax Payer Communication Numbers · Max 1 · Optional

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

          Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.
          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).

       3. 0500 · N3 · APTC Contributor/Tax Payer Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.

       4. 0600 · N4 · APTC Contributor/Tax Payer City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.

   34. 2200 Loop Optional Repeat >1

       1. 2000 · DSB · Disability Information · Max 1 · Mandatory

          To supply disability information

          Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       2. 2100 · DTP · Disability Eligibility Dates · Max 2 · Optional

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

          This segment is used to send the first and last date of disability.
          Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

   35. 2300 Loop Optional Repeat 99

       1. 2600 · HD · Health Coverage · Max 1 · Mandatory

          To provide information on health coverage

          Required when enrolling a new enrollee or when adding, updating, removing coverage or auditing an existing enrollee. If not required by this implementation guide, do not send.

       2. 2700 · DTP · Health Coverage Dates · Max 7 · Mandatory

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

       3. 2900 · REF · Health Coverage Policy Number · Max 5 · Optional

          To specify identifying information

          Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

       4. 2900 · REF · Prior Coverage Months · Max 1 · Optional

          To specify identifying information

          Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act. If not required by this implementation guide, do not send.

       5. 2310 Loop Optional Repeat 10

          1. 3100 · LX · Provider Information · Max 1 · Mandatory

             To reference a line number in a transaction set

             Use one iteration of the loop to identify each applicable health care service provider.
             The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.
             Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

          2. 3200 · NM1 · Provider Name · Max 1 · Mandatory

             To supply the full name of an individual or organizational entity

          3. 3500 · N3 · Provider Address · Max 2 · Optional

             To specify the location of the named party

             Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

          4. 3600 · N4 · Provider City, State, ZIP Code · Max 1 · Optional

             To specify the geographic place of the named party

             Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

          5. 3700 · PER · Provider Communications Numbers · Max 2 · Optional

             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 an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

          6. 3950 · PLA · Provider Change Reason · Max 1 · Optional

             To indicate action to be taken for the location specified and to qualify the location specified

             Required when it is necessary to report the reason and the effective date of the provider changes. If not required by this implementation guide, do not send.

       6. 2320 Loop Optional Repeat 5

          1. 4000 · COB · Coordination of Benefits · Max 1 · Mandatory

             To supply information on coordination of benefits

             Required when an enrollee has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.

          2. 4050 · REF · Coordination of Benefits Enrollee Identifier · Max 2 · Optional

             To specify identifying information

             Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
             Use the Social Security Number until the National ID Number for individuals is available.

          3. 4050 · REF · Coordination of Benefits Payer Group Identifier · Max 1 · Optional

             To specify identifying information

             Required when the group number assigned by this COB payer is known. If not required by this implementation guide, do not send.

          4. 4070 · DTP · Coordination of Benefits Eligibility Begin Date · Max 1 · Optional

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

             Required when the begin date for coordination of benefits has been collected. If not required by this implementation guide, do not send.

          5. 4070 · DTP · Coordination of Benefits Eligibility End Date · Max 2 · Optional

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

             Required when the end date for coordination of benefits has been collected. If not required by this implementation guide, do not send.

          6. 2330 Loop Optional Repeat 1

             1. 4100 · NM1 · Coordination of Benefits Related Entity · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

             2. 4500 · PER · Administrative Communications Contact · Max 1 · Optional

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

                Required when an Exchange has collected the information and the Exchange can legally share the information. If not required by this implementation guide, do not send.

   36. 6880 · LS · Additional Reporting Categories · Max 1 · Optional

       To indicate that the next segment begins a loop

       Required when an Exchange realizes a data need that cannot be accommodated within the other defined data elements in this transaction. If not required by this implementation guide, do not send.

   37. 2700A Loop Optional Repeat >1

       1. 6881 · LX · Agent/Broker Reporting · Max 1 · Mandatory

          To reference a line number in a transaction set

          Required when an Agent/Broker is involved in this enrollment. If not required by this implementation guide, do not send.

       2. 2750A Loop Mandatory Repeat 1

          1. 6882 · N1 · Agent/Broker Name · Max 1 · Mandatory

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

          2. 6883 · REF · Agent/Broker License Number · Max 1 · Mandatory

             To specify identifying information

          3. 6884 · DTP · Agent/Broker Relationship Dates · Max 1 · Mandatory

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

             Use this segment to associate a date or date range with a reporting category.

   38. 2700B Loop Optional Repeat >1

       1. 6881 · LX · Navigator Reporting · Max 1 · Mandatory

          To reference a line number in a transaction set

          Required when a Navigator is involved in this enrollment. If not required by this implementation guide, do not send.

       2. 2750B Loop Mandatory Repeat 1

          1. 6882 · N1 · Navigator Name · Max 1 · Mandatory

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

          2. 6883 · REF · Navigator Identifier · Max 1 · Mandatory

             To specify identifying information

          3. 6884 · DTP · Navigator Relationship Date · Max 1 · Mandatory

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

   39. 2700C Loop Optional Repeat >1

       1. 6881 · LX · Enrollee Reporting Categories · Max 1 · Mandatory

          To reference a line number in a transaction set

          Required when an Exchange realizes a data need that cannot be accommodated within the other defined data elements in this transaction. If not required by this implementation guide, do not send.

       2. 2750C Loop Mandatory Repeat 1

          1. 6882 · N1 · Reporting Category · Max 1 · Mandatory

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

          2. 6883 · REF · Reporting Category Reference · Max 1 · Mandatory

             To specify identifying information

          3. 6884 · DTP · Reporting Category Date · Max 1 · Optional

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

             Required when it is necessary to report effective dates associated with the data reported in REF03 of this loop. If not required by this implementation guide, do not send.
             Use this segment to associate a date or date range with a reporting category.

   40. 6885 · LE · Additional Reporting Categories Loop Termination · Max 1 · Optional

       To indicate that the loop immediately preceding this segment is complete

       Required when the LS segment in position 6880 is sent. If not required by this implementation guide, do not send.

2. 6900 · SE · Transaction Set Trailer · Max 1 · Mandatory

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