Benefit Enrollment and Maintenance (X220A1)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1852*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185224*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*X*20240120*2105*08*X**2~
N1*IN*ANTHEM BLUE CROSS*94*953760001~
N1*P5*XXXXXX*24*XXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20101001~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*IND~
DTP*348*D8*20101001~
GE*1*000000001~
IEA*1*000000001~

Example 1: Enrolling a subscriber effective 10/01/2010

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1853*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185343*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*XXXXX*20240120*1854*02*X**4~
N1*IN*ANTHEM BLUE CROSS*XV*953760001~
N1*P5*XXXX*24*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent3*MIDDLENAME***34*777777777~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19930913*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Enrolling a family effective 10/01/2010

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1854*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185419*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*XX*20240120*1708*ET*XX**4~
N1*IN*ANTHEM BLUE CROSS*94*953760001~
N1*P5*XXX*24*XXXXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*ECH~
DTP*348*D8*20060101~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060101~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060101~
INS*N*01*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20051001~
DTP*349*D8*20101231~
GE*1*000000001~
IEA*1*000000001~

Example 3: Term a spouse effective 12/31/2010; change status from F to S and D

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1855*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185500*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*15*XXXXX*20240120*2009*14*XXX**RX~
N1*IN*ANTHEM BLUE CROSS*XV*953760001~
N1*P5*XX*FI*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20060625~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060601~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060625~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*20060625*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060625~
GE*1*000000001~
IEA*1*000000001~

Example 4: Add dependent to a subscriber and spouse contract effective 06/25/2006

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1855*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185548*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*00*XXXX*20240120*1210*NS*XXXXX**2~
N1*IN*ANTHEM BLUE CROSS*FI*953760001~
N1*P5*XXX*24*XXXXX~
INS*Y*18*024**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*024**HLT*HEALTH 1*FAM~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*19*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*19*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*01*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
GE*1*000000001~
IEA*1*000000001~

Example 5: Term family effective 12/31/2006. Family has been effective since 01/01/2006

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240119*1856*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185621*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*X*20240120*1429*CS*XX**2~
N1*IN*ANTHEM BLUE CROSS*FI*953760001~
N1*P5*XXXXXX*24*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
GE*1*000000001~
IEA*1*000000001~

X12 834 Benefit Enrollment and Maintenance (X220A1)