Sana

X12 834 Sana Inbound - Standard

X12 Release 5010Revised

Feb 18, 8:21 PM

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)

• 005010: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

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 · String (AN) · Min 4 Max 9

ST-03 · 1705 · Implementation Convention Reference · Optional · String (AN) · Min 1 Max 35

0200 Heading > BGN

BGN Beginning Segment

Required · Max use 1

If Time Code (BGN-05) is present, then Time (BGN-04) is required

BGN-01 · 353 · Transaction Set Purpose Code · Required · Identifier (ID) · Min 2 Max 2

BGN-02 · 127 · Reference Identification · Required · String (AN) · Min 1 Max 50

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

BGN-04 · 337 · Time · Optional · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

BGN-05 · 623 · Time Code · Optional · Identifier (ID) · Min 2 Max 2

BGN-08 · 306 · Action Code · Optional · Identifier (ID) · Min 1 Max 2

0300 Heading > REF

REF Reference Information

Optional · Max use >1

REF-01 · 128 · Reference Identification Qualifier · Optional · Identifier (ID) · Min 2 Max 3

REF-02 · 127 · Reference Identification · Optional · String (AN) · Min 1 Max 50

0400 Heading > DTP

DTP Date or Time or Period

Optional · Max use >1

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

• 007: Effective
• 303: Maintenance Effective
• 382: Enrollment

DTP-02 · 1250 · Date Time Period Format Qualifier · Required · Identifier (ID) · Min 2 Max 3

DTP-03 · 1251 · Date Time Period · Required · String (AN) · Min 1 Max 35

0600 Heading > QTY

QTY Quantity Information

Optional · Max use >1

QTY-01 · 673 · Quantity Qualifier · Required · Identifier (ID)

• DT: Dependent Total
• ET: Employee Total
• TO: Total

QTY-02 · 380 · Quantity · Optional · Decimal number (R) · Min 1 Max 15

1000 Loop Required Max >1

0700 Heading > 1000 Loop > N1

N1 Party Identification

Required · Max use 1

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

• IN: Insurer
• P5: Plan Sponsor
• TV: Third Party Administrator (TPA)

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

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

• 24: Employer's Identification Number
• FI: Federal Taxpayer's Identification Number

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

Detail

2000 Loop Required Max >1

0100 Detail > 2000 Loop > INS

INS Insured Benefit

Required · Max use 1

INS-01 · 1073 · Yes/No Condition or Response Code · Required · Identifier (ID)

• N: No
• Y: Yes

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

• 01: Spouse
• 17: Stepson or Stepdaughter
• 18: Self
• 19: Child
• 26: Guardian
• 53: Life Partner

INS-03 · 875 · Maintenance Type Code · Required · Identifier (ID) · Min 3 Max 3

INS-04 · 1203 · Maintenance Reason Code · Optional · Identifier (ID) · Min 2 Max 3

INS-05 · 1216 · Benefit Status Code · Optional · Identifier (ID)

• A: Active
• C: Consolidated Omnibus Budget Reconciliation Act (COBRA)

INS-06 · C052 · Medicare Status Code · Optional Max use 1 · To provide Medicare coverage and associated reason for Medicare eligibility

C052-01 · 1218 · Medicare Plan Code · Required · Identifier (ID) · Min 1 Max 1

INS-07 · 1219 · Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code · Optional · Identifier (ID) · Min 1 Max 2

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

• AC: Active
• FT: Full-time
• PT: Part-time
• RT: Retired
• TE: Terminated

INS-09 · 1220 · Student Status Code · Optional · Identifier (ID) · Min 1 Max 1

INS-10 · 1073 · Yes/No Condition or Response Code · Optional · Identifier (ID) · Min 1 Max 1

0200 Detail > 2000 Loop > REF

REF Reference Information

Required · Max use 2

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

• 0F: Subscriber SSN
• 1L: Group Number

REF-02 · 127 · Reference Identification · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Sub-group · Optional · String (AN) · Min 1 Max 80

0250 Detail > 2000 Loop > DTP

DTP Date or Time or Period

Optional · Max use 2

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

• 336: Employment Begin
• 337: Employment End

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 8 Max 35

2100 Loop Required Max >1

0300 Detail > 2000 Loop > 2100 Loop > NM1

NM1 Individual or Organizational Name

Required · Max use 1

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

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 · Name Last or Organization Name · Required · String (AN) · Min 1 Max 60

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

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

NM1-06 · 1038 · Name Prefix · Optional · String (AN) · Min 1 Max 10

NM1-07 · 1039 · 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 · Identification Code · Optional · String (AN) · Min 9 Max 9

0400 Detail > 2000 Loop > 2100 Loop > PER

PER Administrative Communications Contact

Optional · Max use 1

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
• TE: Telephone
• WP: Work Phone Number

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

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• CP: Cellular Phone
• EM: Electronic Mail
• HP: Home Phone Number
• TE: Telephone
• WP: Work Phone Number

PER-06 · 364 · Communication Number · Optional · String (AN) · Min 1 Max 256

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

• CP: Cellular Phone
• EM: Electronic Mail
• TE: Telephone
• WP: Work Phone Number

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

0500 Detail > 2000 Loop > 2100 Loop > N3

N3 Party Location

Required · Max use 1

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

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

0600 Detail > 2000 Loop > 2100 Loop > N4

N4 Geographic Location

Required · Max use 1

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

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

N4-03 · 116 · Postal Code · Required · Identifier (ID) · Min 5 Max 9

0800 Detail > 2000 Loop > 2100 Loop > DMG

DMG Demographic Information

Optional · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Date Time Period · Required · String (AN) · Min 8 Max 8

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

• F: Female
• M: Male
• U: Unknown

DMG-04 · 1067 · Marital Status Code · Optional · Identifier (ID) · Min 1 Max 1

DMG-06 · 1066 · Citizenship Status Code · Optional · Identifier (ID) · Min 1 Max 2

1100 Detail > 2000 Loop > 2100 Loop > ICM

ICM Individual Income

Optional · Max use 1

ICM-01 · 594 · Frequency Code · Required · Identifier (ID)

• 7: Annual
• H: Hourly

ICM-02 · 782 · Monetary Amount · Required · Decimal number (R) · Min 1 Max 15

ICM-03 · 380 · Quantity · Optional · Decimal number (R) · Min 1 Max 15

ICM-04 · 310 · Location Identifier · Optional · String (AN) · Min 1 Max 30

1300 Detail > 2000 Loop > 2100 Loop > HLH

HLH Health Information

Optional · Max use 1

HLH-01 · 1212 · Health-Related Code · Optional · Identifier (ID) · Min 1 Max 1

2300 Loop Required Max >1

2600 Detail > 2000 Loop > 2300 Loop > HD

HD Health Coverage

Required · Max use 1

HD-01 · 875 · Maintenance Type Code · Required · Identifier (ID) · Min 3 Max 3

HD-02 · 1203 · Maintenance Reason Code · Optional · Identifier (ID) · Min 2 Max 3

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

• DEN: Dental
• HLT: Health
• VIS: Vision

HD-04 · 1204 · Plan Coverage Description · Optional · String (AN) · Min 1 Max 50

HD-05 · 1207 · Coverage Level Code · Optional · Identifier (ID) · Min 3 Max 3

2700 Detail > 2000 Loop > 2300 Loop > DTP

DTP Date or Time or Period

Required · Max use 10

DTP-01 · 374 · Date/Time Qualifier · Required · Identifier (ID) · Max use 2

• 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 · Date Time Period · Required · String (AN) · Min 8 Max 8

2900 Detail > 2000 Loop > 2300 Loop > REF

REF Reference Information

Required · Max use 1

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

• 1L: Policy Number

REF-02 · 127 · Reference Identification · Required · String (AN) · Min 1 Max 50 · ([0-9a-f]{8}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{4}-[0-9a-f]{12}|[A-Z][0-9]{2}(.*)) RegEx pattern

6900 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Number of Included Segments · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · String (AN) · 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

Sample 1

ISA*00*          *00*          *30*260302465      *30*82-1990296     *230119*0814*^*00501*004443162*0*P*>~
GS*BE*260302465*82-1990296*20230119*0814*230108191*X*005010X220A1~
ST*834*FPH6IXWEM*005010X220A1~
BGN*00*FPH6IXWEM*20230119*081419*CS***4~
N1*IN*SANA BENEFITS, INC.*FI*82-1990296~
N1*P5*SANA BENEFITS, INC.*FI*82-1990296~
N1*TV*SANA BENEFITS, INC.*FI*82-1990296~

INS*Y*18*030*XN*A***FT~
REF*0F*837498753~
REF*1L*10001*Sales~
DTP*336*D8*20180207~
NM1*IL*1*FAKERTON*CHAD****34*837498753~
PER*IP**HP*8767362273~
N3*1200 W STATE ST~
N4*COLUMBUS*OH*43205~
DMG*D8*19871018*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*349*D8*20220131~
REF*1L*11111111-1111-4111-8111-111111111111~

INS*Y*18*030*XN*A***FT~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20120122~
NM1*IL*1*CUSTOMER*DAVID*O***34*987378471~
PER*IP**HP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19850807*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*348*D8*20220131~
REF*1L*11111111-1111-4111-A111-333333333333~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*11111111-1111-4111-B111-222222222222~

INS*N*01*030*XN*A~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20190528~
NM1*IL*1*CUSTOMER*JENNA****34*233672876~
PER*IP**HP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19890202*F~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*11111111-1111-4111-a111-222222222222~

SE*47*FPH6IXWEM~
GE*1*230108191~
IEA*1*004443162~

Sample 2

ISA*00*          *00*          *30*260302465      *30*82-1990296     *230119*0814*^*00501*004443162*0*P*>~
GS*BE*260302465*82-1990296*20230119*0814*230108191*X*005010X220A1~
ST*834*FPH6IXWEM*005010X220A1~
BGN*00*FPH6IXWEM*20230119*081419*CS***4~
N1*IN*SANA BENEFITS, INC.*FI*82-1990296~
N1*P5*SANA BENEFITS, INC.*FI*82-1990296~
N1*TV*SANA BENEFITS, INC.*FI*82-1990296~

INS*Y*18*030*XN*A***FT~
REF*0F*837498753~
REF*1L*10001*Sales~
DTP*336*D8*20180207~
NM1*IL*1*FAKERTON*CHAD****34*837498753~
PER*IP**HP*8767362273~
N3*1200 W STATE ST~
N4*COLUMBUS*OH*43205~
DMG*D8*19871018*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*349*D8*20220131~
REF*1L*11111111-aefb-4111-8111-111111111111~

INS*Y*18*030*XN*A***FT~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20120122~
NM1*IL*1*Customer*DAVID*O***34*987378471~
PER*IP**WP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19850807*M*R~
HD*030**HLT**EMP~
DTP*348*D8*20211201~
DTP*349*D8*20220131~
REF*1L*11111111-1111-4111-8111-333333333333~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*11111111-abfe-4111-8111-222222222222~

INS*N*01*030*XN*A~
REF*0F*987378471~
REF*1L*10001~
DTP*336*D8*20190528~
NM1*IL*1*CUSTOMER*JENNA****34*233672876~
PER*IP**HP*8762763890~
N3*444 S High Street~
N4*COLUMBUS*OH*43205~
DMG*D8*19890202*F~
HD*030**HLT**ESP~
DTP*348*D8*20220201~
REF*1L*AB111111-A111-4111-a111-222222222222~

SE*47*FPH6IXWEM~
GE*1*230108191~
IEA*1*004443162~