todd-test

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

X12 Release 5010

Delimiters

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

ISA Interchange Control Header

Required · Max use 1

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

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

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

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

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

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

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

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

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

Codes

• 01: Duns (Dun & Bradstreet)
• 02: SCAC (Standard Carrier Alpha Code)
• 03: FMC (Federal Maritime Commission)
• 04: IATA (International Air Transport Association)
• 07: Global Location Number (GLN)
• 08: UCC EDI Communications ID (Comm ID)
• 09: X.121 (CCITT)
• 10: Department of Defense (DoD) Activity Address Code
• 11: DEA (Drug Enforcement Administration)
• 12: Phone (Telephone Companies)
• 13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
• 14: Duns Plus Suffix
• 15: Petroleum Accountants Society of Canada Company Code
• 16: Duns Number With 4-Character Suffix
• 17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
• 18: Association of American Railroads (AAR) Standard Distribution Code
• 19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
• 20: Health Industry Number (HIN)
• 21: Integrated Postsecondary Education Data System, or (IPEDS)
• 22: Federal Interagency Commission on Education, or FICE
• 23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
• 24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
• 25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
• 26: Statistics of Canada List of Postsecondary Institutions
• 27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
• 29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
• 30: U.S. Federal Tax Identification Number
• 31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
• 32: U.S. Federal Employer Identification Number (FEIN)
• 33: National Association of Insurance Commissioners Company Code (NAIC)
• 34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
• 35: Statistics Canada Canadian College Student Information System Institution Codes
• 36: Statistics Canada University Student Information System Institution Codes
• 37: Society of Property Information Compilers and Analysts
• 38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
• AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
• NR: National Retail Merchants Association (NRMA) - Assigned
• SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
• SN: Standard Address Number
• ZZ: Mutually Defined

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

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

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

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

• ^: Repetition Separator

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

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

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

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

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

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

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

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

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

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

• BE: Benefit Enrollment and Maintenance (834)

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

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

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

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

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

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

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

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

005010X220A1

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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

• 834: Benefit Enrollment and Maintenance

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

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

005010X220A1

0200 Heading > BGN

BGN Beginning Segment

Required · Max use 1

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

• 00: Original

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

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

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

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

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

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

• 2: Change (Update)

0400 Heading > DTP

DTP File Effective Date

Required · Max use >1

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

• 007: Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Date Time Period · Required · Date (DT) · CCYYMMDD format

1000A Sponsor Name Loop Required Max 1

Variants (all may be used)

Payer LoopTPA/Broker Name Loop

0700 Heading > Sponsor Name Loop > N1

N1 Sponsor Name

Required · Max use 1

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

• P5: Plan Sponsor

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

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

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

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

1000B Payer Loop Required Max 1

Variants (all may be used)

Sponsor Name LoopTPA/Broker Name Loop

0700 Heading > Payer Loop > N1

N1 Payer

Required · Max use 1

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

• IN: Insurer

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

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

• FI: Federal Taxpayer's Identification Number

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

1000C TPA/Broker Name Loop Required Max 1

Variants (all may be used)

Sponsor Name LoopPayer Loop

0700 Heading > TPA/Broker Name Loop > N1

N1 TPA/Broker Name

Required · Max use 1

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

• BO: Broker or Sales Office

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

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

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

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

Detail

2000 Member Level Detail Loop Required Max 1

0100 Detail > Member Level Detail Loop > INS

INS Member Level Detail

Required · Max use 1

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

• Y: Yes

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

• 18: Self

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

• 001: Change
• 022: Change in Status
• ZZZ: Mutually Defined

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

• 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)

• A: Active

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

• AC: Active

0200 Detail > Member Level Detail Loop > REF

REF Member Supplemental Identifier

Required · Max use 13

Variants (all may be used)

REFSubscriber Identifier

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

• 17: Client Reporting Category

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

0200 Detail > Member Level Detail Loop > REF

REF Subscriber Identifier

Required · Max use 1

Variants (all may be used)

REFMember Supplemental Identifier

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

• 0F: Subscriber Number

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

0250 Detail > Member Level Detail Loop > DTP

DTP Member Level Dates

Required · Max use 24

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

• 303: Maintenance Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Status Information Effective Date · Required · Date (DT) · CCYYMMDD format

2100A Member Name Loop Required Max 1

Variants (all may be used)

Incorrect Member Name LoopMember Mailing Address Loop

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

NM1 Member Name

Required · Max use 1

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

• IL: Insured or Subscriber

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

• 1: Person

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

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

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

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

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

• 34: Social Security Number

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

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

PER Member Communications Numbers

Required · Max use 1

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

• IP: Insured Party

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

• TE: Telephone

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

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

• EM: Electronic Mail

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

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

N3 Member Residence Street Address

Required · Max use 1

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

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

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

N4 Member City, State, ZIP Code

Required · Max use 1

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

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

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

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

DMG Member Demographics

Required · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Member Birth Date · Required · Date (DT) · CCYYMMDD format

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

• F: Female
• M: Male

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

HLH Member Health Information

Required · Max use 1

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

• N: None
• T: Tobacco Use

2100B Incorrect Member Name Loop Optional Max 1

Variants (all may be used)

Member Name LoopMember Mailing Address Loop

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

NM1 Member Name

Required · Max use 1

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)

• 70: Prior Incorrect Insured

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

• 1: Person

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

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

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

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

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

• 34: Social Security Number

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

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

N3 Member Residence Street Address

Optional · Max use 1

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

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

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

N4 Member City, State, ZIP Code

Optional · Max use 1

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

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

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

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

DMG Member Demographics

Optional · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Member Birth Date · Required · Date (DT) · CCYYMMDD format

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

• F: Female
• M: Male

2100C Member Mailing Address Loop Optional Max 1

Variants (all may be used)

Member Name LoopIncorrect Member Name Loop

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

NM1 Individual or Organizational Name

Required · Max use 1

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

• 31: Postal Mailing Address

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

• 1: Person

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

N3 Member Mail Street Address

Required · Max use 1

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

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

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

N4 Member Mail City, State, ZIP Code

Required · Max use 1

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

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

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

2300 Health Coverage Loop Required Max 99

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

HD Health Coverage

Required · Max use 1

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

• 001: Change

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

• DEN: Dental
• HLT: Health

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

DTP Health Coverage Dates

Required · Max use >1

Variants (all may be used)

DTPHealth Coverage Dates

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

• 348: Benefit Begin

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Coverage Period · Required · Date (DT) · CCYYMMDD format

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

DTP Health Coverage Dates

Required · Max use 6

Variants (all may be used)

DTPHealth Coverage Dates

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

• 303: Maintenance Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Coverage Period · Required · Date (DT) · CCYYMMDD format

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

REF Health Coverage Policy Number

Required · Max use 1

Variants (all may be used)

REFHealth Coverage Policy Number

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

• 1L: Group or Policy Number

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

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

REF Health Coverage Policy Number

Required · Max use 1

Variants (all may be used)

REFHealth Coverage Policy Number

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

• CE: Class of Contract Code

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

6880 Detail > Member Level Detail Loop > LS

LS Loop Header

Required · Max use 1

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

2700 Member Reporting Categories Loop Required Max >1

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

LX Member Reporting Categories

Required · Max use 1

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

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category Loop

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

N1 Reporting Category

Required · Max use 1

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

• 75: Participant

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

ADDL MAINT REASON

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

REF Reporting Category Reference

Required · Max use 1

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

• 17: Client Reporting Category

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

DEMOGRAPHIC CHANGE

LEAVE_PLATFORM

NO CHANGE

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

DTP Reporting Category Date

Required · Max use 1

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

• 007: Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Member Reporting Category Effective Date(s) · Required · Date (DT) · CCYYMMDD format

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category Loop

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

N1 Reporting Category

Required · Max use 1

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

• 75: Participant

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

REQUEST SUBMIT TIMESTAMP

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

REF Reporting Category Reference

Required · Max use 1

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

• 17: Client Reporting Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN) · Min 16 Max 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

6885 Detail > Member Level Detail Loop > LE

LE Loop Trailer

Required · Max use 1

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

6900 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

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

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

GE Functional Group Trailer

Required · Max use 1

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

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

IEA Interchange Control Trailer

Required · Max use 1

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

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

EDI Samples

"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~
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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~
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DTP*007*D8*20240105~
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N1*75*REQUEST SUBMIT TIMESTAMP~
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SE*31*74592441~