Sana
X12 834 Sana Inbound - Standard
X12 Release 5010Revised
Feb 18, 8:21 PM
—
Delimiters
- ~ Segment
- * Element
- > Component
- ^ Repetition
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
detail
2000 Loop
INS
0100
Insured Benefit
Max use 1
Required
REF
0200
Reference Information
Max use 2
Required
DTP
0250
Date or Time or Period
Max use 2
Optional
2100 Loop
NM1
0300
Individual or Organizational Name
Max use 1
Required
PER
0400
Administrative Communications Contact
Max use 1
Optional
N3
0500
Party Location
Max use 1
Required
N4
0600
Geographic Location
Max use 1
Required
DMG
0800
Demographic Information
Max use 1
Optional
ICM
1100
Individual Income
Max use 1
Optional
HLH
1300
Health Information
Max use 1
Optional
SE
6900
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
—
- 00
- No Authorization Information Present (No Meaningful Information in I02)
—
- 00
- No Security Information Present (No Meaningful Information in I04)
—
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
—
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
—
- I
- Information
- P
- Production Data
- T
- Test Data
—
- BE
- Benefit Enrollment and Maintenance (834)
—
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Heading
BGN
0200
Heading > BGN
Beginning Segment
RequiredMax use 1
—
Example
If Time Code (BGN-05) is present, then Time (BGN-04) is required
1000 Loop
RequiredMax >1
—
- IN
- Insurer
- P5
- Plan Sponsor
- TV
- Third Party Administrator (TPA)
—
- 24
- Employer's Identification Number
- FI
- Federal Taxpayer's Identification Number
1000 Loop end
Heading end
Detail
2000 Loop
RequiredMax >1
—
- 01
- Spouse
- 17
- Stepson or Stepdaughter
- 18
- Self
- 19
- Child
- 26
- Guardian
- 53
- Life Partner
—
- A
- Active
- C
- Consolidated Omnibus Budget Reconciliation Act (COBRA)
OptionalMax use 1
To provide Medicare coverage and associated reason for Medicare eligibility
Optional
Identifier (ID)
Min 1Max 2
—
—
- AC
- Active
- FT
- Full-time
- PT
- Part-time
- RT
- Retired
- TE
- Terminated
2100 Loop
RequiredMax >1
NM1
0300
Detail > 2000 Loop > 2100 Loop > NM1
Individual or Organizational Name
RequiredMax use 1
—
Example
If either Identification Code Qualifier (NM1-08) or Identification Code (NM1-09) is present, then the other is required
PER
0400
Detail > 2000 Loop > 2100 Loop > PER
Administrative Communications Contact
OptionalMax use 1
—
Example
—
- CP
- Cellular Phone
- EM
- Electronic Mail
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
—
- CP
- Cellular Phone
- EM
- Electronic Mail
- HP
- Home Phone Number
- TE
- Telephone
- WP
- Work Phone Number
—
- CP
- Cellular Phone
- EM
- Electronic Mail
- TE
- Telephone
- WP
- Work Phone Number
—
- D8
- Date Expressed in Format CCYYMMDD
2100 Loop end
2300 Loop
RequiredMax >1
2300 Loop end
2000 Loop end
Detail end
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~
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~
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~
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