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 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 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 15Max 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 1Max 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 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

:: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

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 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 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

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 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

Transaction Set Header

RequiredMax use 1

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

834: Benefit Enrollment and Maintenance

ST-02

329

Transaction Set Control Number

Required

String (AN)

Min 1Max 9

—

Usage notes

—

ST-03

1705

Implementation Convention Reference

Required

String (AN)

—

Usage notes

—

005010X220A1

BGN

0200

Heading > BGN

Beginning Segment

RequiredMax use 1

—

Example

BGN-01

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

00: Original
—

BGN-02

127

Transaction Set Reference Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

BGN-03

373

Transaction Set Creation Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

BGN-04

337

Transaction Set Creation Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

Usage notes

—

BGN-05

623

Time Code

Optional

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)
—
4: Verify
—
RX: Replace
—

REF

0300

Heading > REF

Reference Information

OptionalMax use >1

—

Example

REF-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

38: Master Policy Number

REF-02

127

Reference Identification

Required

String (AN)

Min 1Max 50

—

DTP

0400

Heading > DTP

Date or Time or Period

OptionalMax use >1

—

Example

DTP-01

374

Date/Time Qualifier

Required

Identifier (ID)

—

007: Effective
303: Maintenance 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

String (AN)

Min 1Max 35

—

QTY

0600

Heading > QTY

Quantity Information

OptionalMax use >1

—

Example

QTY-01

673

Quantity Qualifier

Required

Identifier (ID)

—

DT: Dependent Total
ET: Employee Total
TO: Total

QTY-02

380

Quantity

Required

Decimal number (R)

Min 1Max 15

—

1000A Sponsor Name Loop

RequiredMax 1

Variants (all may be used)

Payer Loop TPA/Broker Name Loop

0700

Heading > Sponsor Name Loop > N1

Sponsor Name

RequiredMax use 1

—

Usage notes

—

Example

N1-01

Entity Identifier Code

Required

Identifier (ID)

—

P5: Plan Sponsor

N1-02

Plan Sponsor Name

Optional

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

FI: Federal Taxpayer's Identification Number

N1-04

Sponsor Identifier

Required

String (AN)

Min 2Max 80

—

1000A Sponsor Name Loop end

1000B Payer Loop

RequiredMax 1

Variants (all may be used)

Sponsor Name Loop TPA/Broker Name Loop

0700

Heading > Payer Loop > N1

Payer

RequiredMax use 1

—

Usage notes

—

Example

N1-01

Entity Identifier Code

Required

Identifier (ID)

—

IN: Insurer

N1-02

Insurer Name

Optional

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

FI: Federal Taxpayer's Identification Number

N1-04

Insurer Identification Code

Required

String (AN)

Min 2Max 80

—

1000B Payer Loop end

1000C TPA/Broker Name Loop

OptionalMax 2

Variants (all may be used)

Sponsor Name Loop Payer Loop

0700

Heading > TPA/Broker Name Loop > N1

TPA/Broker Name

RequiredMax use 1

—

Usage notes

—

Example

N1-01

Entity Identifier Code

Required

Identifier (ID)

—

BO: Broker or Sales Office
TV: Third Party Administrator (TPA)

N1-02

TPA or Broker Name

Required

String (AN)

Min 1Max 60

—

N1-03

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
XV: Centers for Medicare and Medicaid Services PlanID

N1-04

TPA or Broker Identification Code

Required

String (AN)

Min 2Max 80

—

1000C TPA/Broker Name Loop end

Heading end

Detail

2000 Member Level Detail Loop

RequiredMax >1

INS

0100

Detail > Member Level Detail Loop > INS

Member Level Detail

RequiredMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (INS-11) or Date Time Period (INS-12) is present, then the other is required

INS-01

1073

Member Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

Usage notes

—

01: Spouse
18: Self
19: Child
53: Life Partner

INS-03

875

Maintenance Type Code

Required

Identifier (ID)

—

001: Change
—
021: Addition
024: Cancellation or Termination
030: Audit or Compare
—

INS-04

1203

Maintenance Reason Code

Optional

Identifier (ID)

—

01: Divorce
02: Birth
03: Death
04: Retirement
05: Adoption
06: Strike
07: Termination of Benefits
08: Termination of Employment
09: Consolidation Omnibus Budget Reconciliation Act (COBRA)
10: Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11: Surviving Spouse
14: Voluntary Withdrawal
15: Primary Care Provider (PCP) Change
16: Quit
17: Fired
18: Suspended
20: Active
21: Disability
22: Plan Change
25: Change in Identifying Data Elements
26: Declined Coverage
27: Pre-Enrollment
28: Initial Enrollment
29: Benefit Selection
31: Legal Separation
32: Marriage
33: Personnel Data
37: Leave of Absence with Benefits
38: Leave of Absence without Benefits
39: Lay Off with Benefits
40: Lay Off without Benefits
41: Re-enrollment
43: Change of Location
59: Non Payment
AA: Dissatisfaction with Office Staff
AB: Dissatisfaction with Medical Care/Services Rendered
AC: Inconvenient Office Location
AD: Dissatisfaction with Office Hours
AE: Unable to Schedule Appointments in a Timely Manner
AF: Dissatisfaction with Physician's Referral Policy
AG: Less Respect and Attention Time Given than to Other Patients
AH: Patient Moved to a New Location
AI: No Reason Given
AJ: Appointment Times not Met in a Timely Manner
AL: Algorithm Assigned Benefit Selection
EC: Member Benefit Selection
XN: Notification Only
XT: Transfer

INS-05

1216

Benefit Status Code

Optional

Identifier (ID)

—

A: Active
C: Consolidated Omnibus Budget Reconciliation Act (COBRA)
S: Surviving Insured
T: Tax Equity and Fiscal Responsibility Act (TEFRA)

INS-06

C052

Medicare Status Code

OptionalMax use 1

To provide Medicare coverage and associated reason for Medicare eligibility

C052-01

1218

Medicare Plan Code

Required

Identifier (ID)

—

E: No Medicare

INS-08

584

Employment Status Code

Optional

Identifier (ID)

—

Usage notes

—

AC: Active
FT: Full-time
—
PT: Part-time
—
TE: Terminated

INS-09

1220

Student Status Code

Optional

Identifier (ID)

—

F: Full-time
N: Not a Student
P: Part-time

INS-10

1073

Yes/No Condition or Response Code

Optional

Identifier (ID)

—

N: No
U: Unknown
W: Not Applicable
Y: Yes

INS-11

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

INS-12

1251

Date Time Period

Optional

String (AN)

Min 1Max 35

—

REF

0200

Detail > Member Level Detail Loop > REF

Subscriber Identifier

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

REFMember Policy Number REFMember Supplemental Identifier

REF-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0F: Subscriber Number
—

REF-02

127

Subscriber Identifier

Required

String (AN)

Min 9Max 9

^\d{9}$ RegEx pattern

—

REF

0200

Detail > Member Level Detail Loop > REF

Member Policy Number

RequiredMax use 1

—

Example

Variants (all may be used)

REFSubscriber Identifier REFMember Supplemental Identifier

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 4Max 4

^\d{4}$ RegEx pattern

—

REF

0200

Detail > Member Level Detail Loop > REF

Member Supplemental Identifier

OptionalMax use 13

—

Example

Variants (all may be used)

REFSubscriber Identifier REFMember Policy Number

REF-01

128

Reference Identification Qualifier

Required

Identifier (ID)

—

DX: Department/Agency Number
—

REF-02

127

Member Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

DTP

0250

Detail > Member Level Detail Loop > DTP

Member Level Dates

OptionalMax use 5

—

Usage notes

—

Example

DTP-01

374

Date Time Qualifier

Required

Identifier (ID)

—

303: Maintenance Effective
336: Employment Begin
337: Employment End
356: Eligibility Begin
357: Eligibility End

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

String (AN)

Min 8Max 8

^(19|20)\d{2}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$ RegEx pattern

—

2100A Member Name Loop

RequiredMax 1

NM1

0300

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

Member Name

RequiredMax use 1

—

Example

If either Identification Code Qualifier (NM1-08) or Member Identifier (NM1-09) is present, then the other is required

NM1-01

Entity Identifier Code

Required

Identifier (ID)

—

Usage notes

—

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 1Max 60

—

NM1-04

1036

Member First Name

Required

String (AN)

Min 1Max 35

—

NM1-05

1037

Name Middle

Optional

String (AN)

Min 1Max 25

—

NM1-06

1038

Name Prefix

Optional

String (AN)

Min 1Max 10

—

NM1-07

1039

Name Suffix

Optional

String (AN)

Min 1Max 10

—

NM1-08

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—

NM1-09

Member Identifier

Optional

String (AN)

Min 9Max 9

^\d{9}$ RegEx pattern

—

PER

0400

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

Member Communications Numbers

OptionalMax use 1

—

Usage notes

—

Example

If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required

PER-01

366

Contact Function Code

Required

Identifier (ID)

—

IP: Insured Party

PER-03

365

Communication Number Qualifier

Required

Identifier (ID)

—

CP: Cellular Phone
EM: Electronic Mail
HP: Home Phone Number

PER-04

364

Communication Number

Required

String (AN)

Min 1Max 256

—

PER-05

365

Communication Number Qualifier

Optional

Identifier (ID)

—

CP: Cellular Phone
EM: Electronic Mail
HP: Home Phone Number

PER-06

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

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

Member Residence Street Address

OptionalMax use 1

—

Usage notes

—

Example

N3-01

166

Member Address Line

Required

String (AN)

Min 1Max 55

—

N3-02

166

Member Address Line

Optional

String (AN)

Min 1Max 55

—

0600

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

Member City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

N4-01

Member City Name

Required

String (AN)

Min 2Max 30

—

N4-02

156

Member State Code

Optional

Identifier (ID)

Min 2Max 2

—

N4-03

116

Member Postal Zone or Zip Code

Optional

Identifier (ID)

Min 3Max 15

—

DMG

0800

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

Member Demographics

RequiredMax use 1

—

Usage notes

—

Example

DMG-01

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Member Birth Date

Required

String (AN)

Min 8Max 8

^(19|20)\d{2}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$ RegEx pattern

—

DMG-03

1068

Gender Code

Required

Identifier (ID)

—

F: Female
M: Male
U: Unknown
—

DMG-04

1067

Marital Status Code

Optional

Identifier (ID)

—

B: Registered Domestic Partner
D: Divorced
I: Single
M: Married
R: Unreported
S: Separated
U: Unmarried (Single or Divorced or Widowed)
W: Widowed
X: Legally Separated

ICM

1100

Detail > Member Level Detail Loop > Member Name Loop > ICM

Member Income

OptionalMax use 1

—

Usage notes

—

Example

ICM-01

594

Frequency Code

Required

Identifier (ID)

—

7: Annual

ICM-02

782

Wage Amount

Required

Decimal number (R)

Min 1Max 8

—

ICM-03

380

Quantity

Optional

Decimal number (R)

Min 1Max 15

—

ICM-04

310

Location Identifier

Optional

String (AN)

Min 1Max 30

—

HLH

1300

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

Health Information

OptionalMax use 1

—

Example

HLH-01

1212

Health-Related Code

Required

Identifier (ID)

Min 1Max 1

—

HLH-02

Height

Optional

Decimal number (R)

Min 1Max 8

—

HLH-03

Weight

Optional

Decimal number (R)

Min 1Max 10

—

HLH-04

Weight

Optional

Decimal number (R)

Min 1Max 10

—

HLH-05

352

Description

Optional

String (AN)

Min 1Max 80

—

HLH-06

1213

Current Health Condition Code

Optional

Identifier (ID)

Min 1Max 1

—

HLH-07

352

Description

Optional

String (AN)

Min 1Max 80

—

2100A Member Name Loop end

2300 Health Coverage Loop

OptionalMax 99

2600

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

Health Coverage

RequiredMax use 1

—

Example

HD-01

875

Maintenance Type Code

Required

Identifier (ID)

—

Usage notes

—

001: Change
021: Addition
024: Cancellation or Termination
030: Audit or Compare

HD-03

1205

Insurance Line Code

Optional

Identifier (ID)

—

AC: Basic Life
—
ADD: Accidental Death or Dismemberment
—
AF: Supplemental Life
—
AG: Preventative Care/Wellness
BH: Weekly Indemnity
—
DEN: Dental
—
HLT: Health
—
MM: Major Medical
—
PDG: Prescription Drug
VIS: Vision
—

HD-04

1204

Plan Coverage Description

Required

String (AN)

Min 1Max 6

^[1-9]\d{0,5}$ RegEx pattern

—

HD-05

1207

Coverage Level Code

Optional

Identifier (ID)

—

ECH: Employee and Children
EMP: Employee Only
ESP: Employee and Spouse
FAM: Family

DTP

2700

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

Health Coverage Dates

RequiredMax use 6

—

Example

DTP-01

374

Date Time Qualifier

Required

Identifier (ID)

—

348: Benefit Begin
—
349: Benefit End
—

DTP-02

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DTP-03

1251

Coverage Period

Required

String (AN)

Min 8Max 8

^(20)\d{2}(0[1-9]|1[0-2])(0[1-9]|[12]\d|3[01])$ RegEx pattern

—

Example values

```
20240301
```
```
20240331
```

2300 Health Coverage Loop end

2000 Member Level Detail Loop end

6900

Detail > SE

Transaction Set Trailer

RequiredMax use 1

—

Example

SE-01

Transaction Segment Count

Required

Numeric (N0)

Min 1Max 10

—

SE-02

329

Transaction Set Control Number

Required

String (AN)

Min 1Max 9

—

Usage notes

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Detail end

Functional Group Trailer

RequiredMax use 1

—

Example

GE-01

Number of Transaction Sets Included

Required

Numeric (N0)

Min 1Max 6

—

GE-02

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

IEA

Interchange Control Trailer

RequiredMax use 1

—

Example

IEA-01

I16

Number of Included Functional Groups

Required

Numeric (N0)

Min 1Max 5

—

IEA-02

I12

Interchange Control Number

Required

Numeric (N0)

Min 9Max 9

—

EDI Samples

Changes Only File Example

ISA*00* *00* *ZZ*000000000 *ZZ*111111111 *241106*1957*^*00501*000000001*0*T*:~
GS*BE*000000000*111111111*20241120*1957*1*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20250106*1957****2~
N1*P5**FI*000000000~
N1*IN**FI*111111111~
INS*Y*18*001**A***FT~
REF*0F*123450010~
REF*1L*0065~
REF*DX*0065-001~
DTP*336*D8*20220321~
NM1*IL*1*DOE*JANE****34*123450010~
PER*IP**CP*7123894000*EM*JDOE@GMAIL.COM~
N3*17794 GURTHRIE ST~
N4*CARROLL*IA*51401~
DMG*D8*19830120*F~
HD*001**MM*1798~
DTP*348*D8*20241201~
INS*N*01*001**A~
REF*0F*123450010~
REF*1L*0065~
REF*DX*0065-001~
NM1*IL*1*DOE*JAMES****34*123450011~
DMG*D8*19801221*M~
HD*001**MM*1798~
DTP*348*D8*20241201~
INS*Y*18*001**A***PT~
REF*0F*123450020~
REF*1L*0065~
REF*DX*0065-002~
DTP*336*D8*20240125~
DTP*337*D8*20241128~
NM1*IL*1*BROWN*DILLAN****34*123450020~
PER*IP**EM*DBROWN@GMAIL.COM~
N3*15 FLOYD RD~
N4*VERONA*NJ*07044~
DMG*D8*20000120*M~
HD*001**MM*1799~
DTP*348*D8*20241001~
DTP*349*D8*20241130~
SE*39*12345~
GE*1*1~
IEA*1*000000001~

Full File Example

ISA*00* *00* *ZZ*000000000 *ZZ*111111111 *241106*1957*^*00501*000000001*0*T*:~
GS*BE*000000000*111111111*20241206*1957*1*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20241206*1957****4~
N1*P5**FI*000000000~
N1*IN**FI*111111111~
INS*Y*18*030**A***FT~
REF*0F*123450010~
REF*1L*0065~
REF*DX*0065-001~
DTP*336*D8*20220321~
NM1*IL*1*DOE*JANE****34*123450010~
PER*IP**CP*7123894000*EM*JDOE@GMAIL.COM~
N3*17794 GURTHRIE ST~
N4*CARROLL*IA*51401~
DMG*D8*19830120*F~
HD*030**MM*1710~
DTP*348*D8*20241201~
INS*N*01*030**A~
REF*0F*123450010~
REF*1L*0065~
REF*DX*0065-001~
NM1*IL*1*DOE*JAMES****34*123450011~
DMG*D8*19801221*M~
HD*030**MM*1710~
DTP*348*D8*20241201~
DTP*349*D8*20241231~
INS*N*19*030**A~
REF*0F*123450010~
REF*1L*0065~
REF*DX*0065-002~
NM1*IL*1*DOE*LISA****34*123450012~
DMG*D8*20101015*F~
HD*030**MM*1711~
DTP*348*D8*20241201~
INS*Y*18*030**A***PT~
REF*0F*123450020~
REF*1L*0065~
REF*DX*0065-002~
DTP*336*D8*20240905~
DTP*337*D8*20241227~
NM1*IL*1*BROWN*DILLAN****34*123450020~
PER*IP**EM*DBROWN@GMAIL.COM~
N3*15 FLOYD RD~
N4*VERONA*NJ*07044~
DMG*D8*20000120*M~
HD*030**MM*1712~
DTP*348*D8*20250101~
DTP*349*D8*20241231~
SE*48*12345~
GE*1*1~
IEA*1*000000001~

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