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
- 0100Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 0200Beginning SegmentMandatoryMax 1
To indicate the beginning of a transaction set
- 0300Exchange Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0300Issuer Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0300Exchange Assigned Employer Group IdentifierOptionalMax 1
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. - 0300Issuer Assigned Employer Group IdentifierOptionalMax 1
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. - 0400File Effective DateMandatoryMax 1
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. - 0600Transaction Set Control TotalsMandatoryMax 1
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). - 0600Dependent Record CountOptionalMax 1
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. - 0600Subscriber Record CountOptionalMax 1
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. - 1000A Loop MandatoryRepeat 1
- 0700Submitter NameMandatoryMax 1
To identify a party by type of organization, name, and code
- 0700Submitter NameMandatoryMax 1
- 1000B Loop MandatoryRepeat 1
- 0700Receiver NameMandatoryMax 1
To identify a party by type of organization, name, and code
- 0700Receiver NameMandatoryMax 1
- 1000C Loop MandatoryRepeat 1
- 0700QHP IssuerMandatoryMax 1
To identify a party by type of organization, name, and code
- 0700QHP IssuerMandatoryMax 1
- 1000D Loop OptionalRepeat 1
- 0700Sponsor NameMandatoryMax 1
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.
- 0700Sponsor NameMandatoryMax 1
- 1000E Loop OptionalRepeat >1
- 0700Sponsor/Employer Group Setup - NameMandatoryMax 1
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. - 0900Primary Billing AddressMandatoryMax 1
To specify the location of the named party
- 1000Primary Billing City, State, ZIP CodeMandatoryMax 1
To specify the geographic place of the named party
- 1100Primary Contact InformationMandatoryMax 1
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). - 1100Alternate Contact InformationOptionalMax 1
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). - 1100EA Loop MandatoryRepeat 1
- 1200Sponsor/Employer Group InformationMandatoryMax 1
To specify account information
- 1300Exchange Assigned Employer Group IdentifierMandatoryMax 1
To specify identifying information
- 1300Employer SizeMandatoryMax 1
To specify identifying information
- 1300Employer ClassificationMandatoryMax 1
To specify identifying information
- 1300Employer Dependent InformationOptionalMax 1
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. - 1400Alternate Billing AddressOptionalMax 1
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. - 1500Alternate Billing City, State, ZIP CodeOptionalMax 1
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. - 1600Alternate Billing Contact InformationOptionalMax 1
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). - 1700Employer Waiting PeriodMandatoryMax 1
To specify any or all of a date, a time, or a time period
- 1800Employer ContributionMandatoryMax 1
To indicate the total monetary amount
- 1200Sponsor/Employer Group InformationMandatoryMax 1
- 1100EB Loop OptionalRepeat 9
- 1200Sponsor/Employer Group Other Location InformationMandatoryMax 1
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. - 1400Sponsor/Employer Group Other Location Street AddressMandatoryMax 1
To specify the location of the named party
- 1500Sponsor/Employer Group Other Location City, State, ZIP CodeMandatoryMax 1
To specify the geographic place of the named party
- 1600Sponsor/Employer Group Other Location Contact InformationOptionalMax 1
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).
- 1200Sponsor/Employer Group Other Location InformationMandatoryMax 1
- 0700Sponsor/Employer Group Setup - NameMandatoryMax 1
Detail
- 2000 Loop MandatoryRepeat >1
- 0100Enrollee Level DetailMandatoryMax 1
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. - 0200Exchange Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0200Issuer Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0200Coverage Specific Exchange Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0200Coverage Specific Issuer Assigned Qualified Health Plan IdentifierOptionalMax 1
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. - 0200Exchange Assigned Employer Group IdentifierOptionalMax 1
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. - 0200Issuer Assigned Employer Group IdentifierOptionalMax 1
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. - 0200Coverage Specific Exchange Assigned Employer Group IdentifierOptionalMax 1
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. - 0200Coverage Specific Issuer Assigned Employer Group IdentifierOptionalMax 1
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. - 0200Exchange Assigned Policy IdentifierMandatoryMax 1
To specify identifying information
For the purposes of this implementation, policy is defined as the collective of enrollees constituting a family unit or household. - 0200Issuer Assigned Policy IdentifierOptionalMax 1
To specify identifying information
Required when known by the submitter. If not required by this implementation guide, do not send. - 0200Exchange Assigned Subscriber IdentifierMandatoryMax 1
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. - 0200Issuer Assigned Subscriber IdentifierOptionalMax 1
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. - 0200Exchange Assigned Dependent IdentifierOptionalMax 1
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. - 0200Issuer Assigned Dependent IdentifierOptionalMax 1
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. - 0200Exchange Assigned APTC Contributor/Tax Payer IdentifierOptionalMax 1
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. - 0200Issuer Assigned APTC Contributor/Tax Payer IdentifierOptionalMax 1
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. - 0200Enrollee Supplemental IdentifierOptionalMax 2
To specify identifying information
Required when sending additional identifying information on the enrollee. If not required by this implementation guide, do not send. - 0200ACH Bank InformationOptionalMax 1
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. - 0200Credit/Debit Card InformationOptionalMax 1
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. - 0250Enrollee Level DatesOptionalMax 18
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. - 0250Indian Tribal Status Effective DateOptionalMax 1
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. - 0250Tobacco Status Effective DateOptionalMax 1
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. - 0250Credit Card Expiration DateOptionalMax 1
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. - 2100A Loop MandatoryRepeat 1
- 0300Enrollee NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 0400Enrollee Communications NumbersOptionalMax 1
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. - 0500Enrollee Residence Street AddressOptionalMax 1
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. - 0600Enrollee City, State, ZIP CodeOptionalMax 1
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. - 0800Enrollee DemographicsOptionalMax 1
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. - 1000Employment ClassOptionalMax >1
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. - 1300Enrollee Health InformationOptionalMax 1
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. - 1400Enrollment Amount InformationOptionalMax 10
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. - 1500Enrollee LanguageOptionalMax >1
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.
- 0300Enrollee NameMandatoryMax 1
- 2100B Loop OptionalRepeat 1
- 0300Incorrect Enrollee NameMandatoryMax 1
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. - 0800Incorrect Enrollee DemographicsOptionalMax 1
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.
- 0300Incorrect Enrollee NameMandatoryMax 1
- 2100C Loop OptionalRepeat 1
- 0300Enrollee Mailing AddressMandatoryMax 1
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. - 0500Enrollee Mail Street AddressMandatoryMax 1
To specify the location of the named party
- 0600Enrollee Mail City, State, ZIP CodeMandatoryMax 1
To specify the geographic place of the named party
- 0300Enrollee Mailing AddressMandatoryMax 1
- 2100D Loop OptionalRepeat 3
- 0300Enrollee EmployerMandatoryMax 1
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. - 0400Enrollee Employer Communications NumbersOptionalMax 1
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. - 0500Enrollee Employer Street AddressOptionalMax 1
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. - 0600Enrollee Employer City, State, ZIP CodeOptionalMax 1
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.
- 0300Enrollee EmployerMandatoryMax 1
- 2100E Loop OptionalRepeat 1
- 0300Custodial ParentMandatoryMax 1
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. - 0400Custodial Parent Communications NumbersOptionalMax 1
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. - 0500Custodial Parent Street AddressOptionalMax 1
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. - 0600Custodial Parent City, State, ZIP CodeOptionalMax 1
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.
- 0300Custodial ParentMandatoryMax 1
- 2100F Loop OptionalRepeat 13
- 0300Responsible PersonMandatoryMax 1
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. - 0400Responsible Person Communications NumbersOptionalMax 1
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. - 0500Responsible Person Street AddressOptionalMax 1
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. - 0600Responsible Person City, State, ZIP CodeOptionalMax 1
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.
- 0300Responsible PersonMandatoryMax 1
- 2100G Loop OptionalRepeat 1
- 0300Drop Off LocationMandatoryMax 1
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. - 0500Drop Off Location Street AddressMandatoryMax 1
To specify the location of the named party
- 0600Drop Off Location City, State, ZIP CodeMandatoryMax 1
To specify the geographic place of the named party
- 0300Drop Off LocationMandatoryMax 1
- 2100H Loop OptionalRepeat 1
- 0300Sponsor NameMandatoryMax 1
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.
- 0300Sponsor NameMandatoryMax 1
- 2100I Loop OptionalRepeat 1
- 0300APTC Contributor/Tax Payer NameMandatoryMax 1
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. - 0400APTC Contributor/Tax Payer Communication NumbersOptionalMax 1
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). - 0500APTC Contributor/Tax Payer Street AddressOptionalMax 1
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. - 0600APTC Contributor/Tax Payer City, State, ZIP CodeOptionalMax 1
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.
- 0300APTC Contributor/Tax Payer NameMandatoryMax 1
- 2200 Loop OptionalRepeat >1
- 2000Disability InformationMandatoryMax 1
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. - 2100Disability Eligibility DatesOptionalMax 2
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.
- 2000Disability InformationMandatoryMax 1
- 2300 Loop OptionalRepeat 99
- 2600Health CoverageMandatoryMax 1
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. - 2700Health Coverage DatesMandatoryMax 7
To specify any or all of a date, a time, or a time period
- 2900Health Coverage Policy NumberOptionalMax 5
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. - 2900Prior Coverage MonthsOptionalMax 1
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. - 2310 Loop OptionalRepeat 10
- 3100Provider InformationMandatoryMax 1
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. - 3200Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 3500Provider AddressOptionalMax 2
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. - 3600Provider City, State, ZIP CodeOptionalMax 1
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. - 3700Provider Communications NumbersOptionalMax 2
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. - 3950Provider Change ReasonOptionalMax 1
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.
- 3100Provider InformationMandatoryMax 1
- 2320 Loop OptionalRepeat 5
- 4000Coordination of BenefitsMandatoryMax 1
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. - 4050Coordination of Benefits Enrollee IdentifierOptionalMax 2
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. - 4050Coordination of Benefits Payer Group IdentifierOptionalMax 1
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. - 4070Coordination of Benefits Eligibility Begin DateOptionalMax 1
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. - 4070Coordination of Benefits Eligibility End DateOptionalMax 2
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. - 2330 Loop OptionalRepeat 1
- 4100Coordination of Benefits Related EntityMandatoryMax 1
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. - 4500Administrative Communications ContactOptionalMax 1
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.
- 4100Coordination of Benefits Related EntityMandatoryMax 1
- 4000Coordination of BenefitsMandatoryMax 1
- 2600Health CoverageMandatoryMax 1
- 6880Additional Reporting CategoriesOptionalMax 1
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. - 2700A Loop OptionalRepeat >1
- 6881Agent/Broker ReportingMandatoryMax 1
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. - 2750A Loop MandatoryRepeat 1
- 6882Agent/Broker NameMandatoryMax 1
To identify a party by type of organization, name, and code
- 6883Agent/Broker License NumberMandatoryMax 1
To specify identifying information
- 6884Agent/Broker Relationship DatesMandatoryMax 1
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.
- 6882Agent/Broker NameMandatoryMax 1
- 6881Agent/Broker ReportingMandatoryMax 1
- 2700B Loop OptionalRepeat >1
- 6881Navigator ReportingMandatoryMax 1
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. - 2750B Loop MandatoryRepeat 1
- 6882Navigator NameMandatoryMax 1
To identify a party by type of organization, name, and code
- 6883Navigator IdentifierMandatoryMax 1
To specify identifying information
- 6884Navigator Relationship DateMandatoryMax 1
To specify any or all of a date, a time, or a time period
- 6882Navigator NameMandatoryMax 1
- 6881Navigator ReportingMandatoryMax 1
- 2700C Loop OptionalRepeat >1
- 6881Enrollee Reporting CategoriesMandatoryMax 1
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. - 2750C Loop MandatoryRepeat 1
- 6882Reporting CategoryMandatoryMax 1
To identify a party by type of organization, name, and code
- 6883Reporting Category ReferenceMandatoryMax 1
To specify identifying information
- 6884Reporting Category DateOptionalMax 1
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.
- 6882Reporting CategoryMandatoryMax 1
- 6881Enrollee Reporting CategoriesMandatoryMax 1
- 6885Additional Reporting Categories Loop TerminationOptionalMax 1
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.
- 0100Enrollee Level DetailMandatoryMax 1
- 6900Transaction Set TrailerMandatoryMax 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)