(FFE to FFE Issuer) 834 Benefit Enrollment and Maintenance (X220A1) v7.0

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*43*A***AC~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**TE*7172343334*AP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**HLT~
DTP*348*D8*19960601~
SE*20*12345~
GE*1*000000103~
IEA*1*000000103~

834 Outbound Envelope

Example 1: Enroll an Employee in Multiple Health Care Insurance Products

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001**A***AC~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~

Example 10: Reinstate member eligibility (INS)

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*43*A***AC~
REF*0F*202443307~
REF*1L*123456001~
DTP*356*D8*19960112~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
PER*IP**TE*7172343334*AP*7172341240~
N3*1715 SOUTHWIND AVENUE~
N4*ANYTOWN*PA*171110000~
DMG*D8*19700614*M~
HD*021**HLT~
DTP*348*D8*19960601~
SE*16*12345~
GE*1*000000103~
IEA*1*000000103~

Example 3: Enroll an Employee in a Managed Care Product

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001*43*A***AC~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****34*2024433307~
HD*021**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 4: Add Subscriber Coverage

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5*GENERIC INC*FI*000111000~
N1*IN*ABC INSURANCE*FI*654456654~
INS*Y*18*001*25*A***AC~
REF*0F*123456789~
REF*1L*123456001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19500415*M~
NM1*70*1*DOE*JAMES*E~
DMG*D8*19500416*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 5: Change subscriber information

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*024*07*A~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19960801~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 6: Cancel a dependent

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*024*43*A***TE~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~

Example 7: Terminate Eligibility for a Subscriber

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001*43*A***AC~
REF*0F*123456789~
REF*1L*123456001~
DTP*303*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*11*12345~
GE*1*000000103~
IEA*1*000000103~

Example 8: Reinstate an Employee

ISA*00*          *00*          *ZZ*SENDERNAME     *ZZ*RECEIVERNAME   *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001**A***AC~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
HD*001**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

X12 834 (FFE to FFE Issuer) 834 Benefit Enrollment and Maintenance (X220A1) v7.0