X12 834 Stedi X12 HIPAA ICHRA 834 Benefit Enrollment and Maintenance (X220A1) v0.5

X12 Release 5010Revised

Mar 19, 2024, 9:24 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)

005010X220A1

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

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

• 834: Benefit Enrollment and Maintenance

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

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

005010X220A1

0200 Heading > BGN

BGN Beginning Segment

Required · Max use 1

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

• 00: Original
• 15: Re-Submission
• 22: Information Copy

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

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

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

BGN-05 · 623 · Time Zone Code · 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-06 · 127 · Original Transaction Set Reference Number · Optional · String (AN) · Min 1 Max 50

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

• 2: Change (Update)
• 4: Verify
• RX: Replace

0300 Heading > REF

REF Transaction Set Policy Number

Optional · Max use 1

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

• 38: Master Policy Number

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

0400 Heading > DTP

DTP File Effective Date

Optional · Max use >1

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

• 007: Effective
• 090: Report Start
• 091: Report End
• 303: Maintenance Effective
• 382: Enrollment
• 388: Payment Commencement
• 950: Application

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 1 Max 35

0600 Heading > QTY

QTY Transaction Set Control Totals

Optional · Max use 3

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

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

QTY-02 · 380 · Record Totals · Required · Decimal number (R) · Min 1 Max 15

1000A Sponsor Name Loop Required Max 1

Variants (all may be used)

Payer LoopTPA/Broker Name Loop

0700 Heading > Sponsor Name Loop > N1

N1 Sponsor Name

Required · Max use 1

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

• P5: Plan Sponsor

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

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

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

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

1000B Payer Loop Required Max 1

Variants (all may be used)

Sponsor Name LoopTPA/Broker Name Loop

0700 Heading > Payer Loop > N1

N1 Payer

Required · Max use 1

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

• IN: Insurer

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

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

• FI: Federal Taxpayer's Identification Number

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

1000C TPA/Broker Name Loop Optional Max 2

Variants (all may be used)

Sponsor Name LoopPayer Loop

0700 Heading > TPA/Broker Name Loop > N1

N1 TPA/Broker Name

Required · Max use 1

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

• BO: Broker or Sales Office

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

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

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

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

1100C TPA/Broker Account Information Loop Optional Max 1

1200 Heading > TPA/Broker Name Loop > TPA/Broker Account Information Loop > ACT

ACT TPA/Broker Account Information

Required · Max use 1

ACT-01 · 508 · TPA or Broker Account Number · Required · String (AN) · Min 1 Max 35

ACT-06 · 508 · TPA or Broker Account Number · Optional · String (AN) · Min 1 Max 35

Detail

2000 Member Level Detail Loop Required Max >1

0100 Detail > Member Level Detail Loop > INS

INS Member Level Detail

Required · Max use 1

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

• N: No
• Y: Yes

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

• 01: Spouse
• 03: Father or Mother
• 04: Grandfather or Grandmother
• 05: Grandson or Granddaughter
• 06: Uncle or Aunt
• 07: Nephew or Niece
• 08: Cousin
• 09: Adopted Child
• 10: Foster Child
• 11: Son-in-law or Daughter-in-law
• 12: Brother-in-law or Sister-in-law
• 13: Mother-in-law or Father-in-law
• 14: Brother or Sister
• 15: Ward
• 16: Stepparent
• 17: Stepson or Stepdaughter
• 18: Self
• 19: Child
• 23: Sponsored Dependent
• 24: Dependent of a Minor Dependent
• 25: Ex-spouse
• 26: Guardian
• 31: Court Appointed Guardian
• 38: Collateral Dependent
• 53: Life Partner
• 60: Annuitant
• D2: Trustee
• G8: Other Relationship
• G9: Other Relative

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

• 001: Change
• 021: Addition
• 024: Cancellation or Termination

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

• 02: Birth
• 03: Death
• 05: Adoption
• 07: Termination of Benefits
• 14: Voluntary Withdrawal
• 25: Change in Identifying Data Elements
• 41: Re-enrollment
• 43: Change of Location
• 69: Failure to Pay Deductible
• 70: Misrepresented Information
• EC: Member Benefit Selection

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

• A: Active

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

• AC: Active
• TE: Terminated

0200 Detail > Member Level Detail Loop > REF

REF Member Policy Number

Optional · Max use 1

Variants (all may be used)

REFMember Supplemental IdentifierREFSubscriber 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 1 Max 50

0200 Detail > Member Level Detail Loop > REF

REF Member Supplemental Identifier

Optional · Max use 13

Variants (all may be used)

REFMember Policy NumberREFSubscriber Identifier

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

• 6O: Cross Reference Number
• 17: Client Reporting Category
• 23: Client Number
• PRT: Product Type
• ZZ: Mutually Defined

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

0200 Detail > Member Level Detail Loop > REF

REF Subscriber Identifier

Required · Max use 1

Variants (all may be used)

REFMember Policy NumberREFMember Supplemental Identifier

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

• 0F: Subscriber Number

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

0250 Detail > Member Level Detail Loop > DTP

DTP Member Level Dates

Optional · Max use 24

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

• 303: Maintenance Effective
• 336: Employment Begin
• 356: Eligibility Begin
• 357: Eligibility End
• EDL: Qualified

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 1 Max 35

2100A Member Name Loop Required Max 1

Variants (all may be used)

Incorrect Member Name LoopMember Mailing Address LoopMember Employer LoopCustodial Parent LoopResponsible Person Loop

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

NM1 Member Name

Required · Max use 1

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

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

• IL: Insured or Subscriber

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

• 1: Person

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

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

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

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

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

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

• 34: Social Security Number

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

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

PER Member Communications Numbers

Optional · Max use 1

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

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) 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)

• TE: Telephone

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

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

• AP: Alternate Telephone

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

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

• BN: Beeper Number
• EM: Electronic Mail

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

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

N3 Member Residence Street Address

Optional · Max use 1

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

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

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

N4 Member City, State, ZIP Code

Optional · Max use 1

Only one of Member State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Location Identifier (N4-06) is present, then Location Qualifier (N4-05) is required

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

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

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

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

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-05 · 309 · Location Qualifier · Optional · Identifier (ID)

• CY: County/Parish

N4-06 · 310 · Location Identifier · Optional · String (AN) · Min 1 Max 30

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

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

DMG Member Demographics

Optional · Max use 1

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

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Member Birth Date · Required · String (AN) · Min 1 Max 35

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

• F: Female
• M: Male

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

• M: Married
• R: Unreported
• U: Unmarried (Single or Divorced or Widowed)

DMG-05 · C056 · Composite Race or Ethnicity Information · Optional Max use 10 · To send general and detailed information on race or ethnicity · Usage notes · If either Code List Qualifier Code (C056 - 02) or Race or Ethnicity Code (C056 - 03) is present, then the other is required

C056-01 · 1109 · Race or Ethnicity Code · Optional · Identifier (ID)

• 7: Not Provided
• 8: Not Applicable
• A: Asian or Pacific Islander
• B: Black
• C: Caucasian
• D: Subcontinent Asian American
• E: Other Race or Ethnicity
• F: Asian Pacific American
• G: Native American
• H: Hispanic
• I: American Indian or Alaskan Native
• J: Native Hawaiian
• N: Black (Non-Hispanic)
• O: White (Non-Hispanic)
• P: Pacific Islander
• Z: Mutually Defined

C056-02 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RET: Classification of Race or Ethnicity

C056-03 · 1271 · Race or Ethnicity Code · Optional · String (AN)

• 1002-5: American Indian or Alaskan Native
• 2028-9: Other Asian
• 2029-7: Asian Indian
• 2034-7: Chinese
• 2036-2: Filipino
• 2039-6: Japanese
• 2040-4: Korean
• 2047-9: Vietnamese
• 2054-5: Black or African American
• 2079-2: Native Hawaiian
• 2080-0: Samoan
• 2086-7: Guamanian or Chamorro
• 2106-3: White
• 2131-1: Other Race
• 2135-2: Hispanic
• 2148-5: Mexican, Mexican American, or Chicano/a
• 2180-8: Puerto Rican
• 2182-4: Cuban
• 2186-5: Not Hispanic
• 2500-7: Other Pacific Islander

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

HLH Member Health Information

Optional · Max use 1

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

• N: None
• T: Tobacco Use

1500 Detail > Member Level Detail Loop > Member Name Loop > LUI

LUI Member Language

Optional · Max use >1

If either Identification Code Qualifier (LUI-01) or Language Code (LUI-02) is present, then the other is required

If Language Use Indicator (LUI-04) is present, then Language Code (LUI-02) is required

LUI-01 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• LD: NISO Z39.53 Language Codes

LUI-02 · 67 · Language Code · Optional · String (AN) · Min 2 Max 80

LUI-04 · 1303 · Language Use Indicator · Optional · Identifier (ID)

• 6: Language Writing
• 7: Language Speaking

2100B Incorrect Member Name Loop Optional Max 1

Variants (all may be used)

Member Name LoopMember Mailing Address LoopMember Employer LoopCustodial Parent LoopResponsible Person Loop

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

NM1 Incorrect Member Name

Required · Max use 1

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

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

• 70: Prior Incorrect Insured

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

• 1: Person

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

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

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

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

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

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

• 34: Social Security Number
• ZZ: Mutually Defined

NM1-09 · 67 · Prior Incorrect Insured Identifier · Optional · String (AN) · Min 2 Max 80

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

DMG Incorrect Member Demographics

Optional · Max use 1

If either Date Time Period Format Qualifier (DMG-01) or Prior Incorrect Insured Birth Date (DMG-02) is present, then the other is required

If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required

If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required

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

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Prior Incorrect Insured Birth Date · Optional · String (AN) · Min 1 Max 35

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

• F: Female
• M: Male

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

• M: Married
• R: Unreported
• U: Unmarried (Single or Divorced or Widowed)

DMG-05 · C056 · Composite Race or Ethnicity Information · Optional Max use 10 · To send general and detailed information on race or ethnicity · Usage notes · If either Code List Qualifier Code (C056 - 02) or Race or Ethnicity Code (C056 - 03) is present, then the other is required

C056-01 · 1109 · Race or Ethnicity Code · Optional · Identifier (ID)

• 7: Not Provided
• 8: Not Applicable
• A: Asian or Pacific Islander
• B: Black
• C: Caucasian
• D: Subcontinent Asian American
• E: Other Race or Ethnicity
• F: Asian Pacific American
• G: Native American
• H: Hispanic
• I: American Indian or Alaskan Native
• J: Native Hawaiian
• N: Black (Non-Hispanic)
• O: White (Non-Hispanic)
• P: Pacific Islander
• Z: Mutually Defined

C056-02 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• RET: Classification of Race or Ethnicity

C056-03 · 1271 · Race or Ethnicity Code · Optional · String (AN)

• 1002-5: American Indian or Alaskan Native
• 2028-9: Other Asian
• 2029-7: Asian Indian
• 2034-7: Chinese
• 2036-2: Filipino
• 2039-6: Japanese
• 2040-4: Korean
• 2047-9: Vietnamese
• 2054-5: Black or African American
• 2079-2: Native Hawaiian
• 2080-0: Samoan
• 2086-7: Guamanian or Chamorro
• 2106-3: White
• 2131-1: Other Race
• 2135-2: Hispanic
• 2148-5: Mexican, Mexican American, or Chicano/a
• 2180-8: Puerto Rican
• 2182-4: Cuban
• 2186-5: Not Hispanic
• 2500-7: Other Pacific Islander

DMG-06 · 1066 · Citizenship Status Code · Optional · Identifier (ID)

• 1: U.S. Citizen
• 2: Non-Resident Alien
• 3: Resident Alien
• 4: Illegal Alien
• 5: Alien
• 6: U.S. Citizen - Non-Resident
• 7: U.S. Citizen - Resident

DMG-10 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• REC: Race or Ethnicity Collection Code

DMG-11 · 1271 · Race or Ethnicity Collection Code · Optional · String (AN) · Min 1 Max 30

2100C Member Mailing Address Loop Optional Max 1

Variants (all may be used)

Member Name LoopIncorrect Member Name LoopMember Employer LoopCustodial Parent LoopResponsible Person Loop

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

NM1 Member Mailing Address

Required · Max use 1

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

• 31: Postal Mailing Address

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

• 1: Person

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

N3 Member Mail Street Address

Required · Max use 1

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

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

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

N4 Member Mail City, State, ZIP Code

Required · Max use 1

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

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

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

2100D Member Employer Loop Optional Max 3

Variants (all may be used)

Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopCustodial Parent LoopResponsible Person Loop

0300 Detail > Member Level Detail Loop > Member Employer Loop > NM1

NM1 Member Employer Address

Required · Max use 1

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

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

• 36: Employer

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

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Member Employer Name · Optional · String (AN) · Min 1 Max 60

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

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

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

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

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

• 24: Employer's Identification Number
• 34: Social Security Number

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

Example values

• 123456

• 14566874

0400 Detail > Member Level Detail Loop > Member Employer Loop > PER

PER Member Employer Communications Numbers

Optional · Max use 1

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

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required

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

• EP: Employer Contact

PER-02 · 93 · Member Employer Communications Contact Name · Optional · String (AN) · Min 1 Max 60

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

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

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

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

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

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

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

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone

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

0500 Detail > Member Level Detail Loop > Member Employer Loop > N3

N3 Member Employer Street Address

Optional · Max use 1

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

Example values

• 166 Columbia St

• Apt 4

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

0600 Detail > Member Level Detail Loop > Member Employer Loop > N4

N4 Member Employer City, State, ZIP Code

Optional · Max use 1

Only one of Member Employer State Code (N4-02) or Country Subdivision Code (N4-07) may be present

If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required

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

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

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

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

1200 Detail > Member Level Detail Loop > Member Employer Loop > AMT

AMT Monetary Amount Information

Optional · Max use 10

AMT-01 · 522 · Amount Qualifier Code · Required · Identifier (ID)

• 93: Contribution

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

2100F Custodial Parent Loop Optional Max 1

Variants (all may be used)

Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopResponsible Person Loop

0300 Detail > Member Level Detail Loop > Custodial Parent Loop > NM1

NM1 Custodial Parent

Required · Max use 1

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

• S3: Custodial Parent

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

• 1: Person

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

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

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

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

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

• 34: Social Security Number

0400 Detail > Member Level Detail Loop > Custodial Parent Loop > PER

PER Custodial Parent Communications Numbers

Optional · Max use 1

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

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required

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

• PQ: Parent or Guardian

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

• TE: Telephone

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

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

• AP: Alternate Telephone

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

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

• BN: Beeper Number
• EM: Electronic Mail

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

0500 Detail > Member Level Detail Loop > Custodial Parent Loop > N3

N3 Custodial Parent Street Address

Optional · Max use 1

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

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

0600 Detail > Member Level Detail Loop > Custodial Parent Loop > N4

N4 Custodial Parent City, State, ZIP Code

Optional · Max use 1

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

N4-02 · 156 · Custodial Parent State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Custodial Parent Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

2100G Responsible Person Loop Optional Max 13

Variants (all may be used)

Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopCustodial Parent Loop

0300 Detail > Member Level Detail Loop > Responsible Person Loop > NM1

NM1 Responsible Person

Required · Max use 1

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

• S1: Parent

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

• 1: Person

NM1-03 · 1035 · Responsible Party Last or Organization Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Responsible Party First Name · Optional · String (AN) · Min 1 Max 35

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

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

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

0400 Detail > Member Level Detail Loop > Responsible Person Loop > PER

PER Responsible Person Communications Numbers

Optional · Max use 1

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

If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required

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

• RP: Responsible Person

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

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• HP: Home Phone Number
• TE: Telephone
• WP: Work Phone Number

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

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

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• 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)

• AP: Alternate Telephone
• BN: Beeper Number
• CP: Cellular Phone
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• HP: Home Phone Number
• TE: Telephone
• WP: Work Phone Number

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

0500 Detail > Member Level Detail Loop > Responsible Person Loop > N3

N3 Responsible Person Street Address

Optional · Max use 1

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

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

0600 Detail > Member Level Detail Loop > Responsible Person Loop > N4

N4 Responsible Person City, State, ZIP Code

Optional · Max use 1

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

N4-02 · 156 · Responsible Person State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Responsible Person Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

2200 Disability Information Loop Optional Max >1

2000 Detail > Member Level Detail Loop > Disability Information Loop > DSB

DSB Disability Information

Required · Max use 1

If either Product or Service ID Qualifier (DSB-07) or Diagnosis Code (DSB-08) is present, then the other is required

DSB-01 · 1146 · Disability Type Code · Required · Identifier (ID)

• 1: Short Term Disability
• 2: Long Term Disability
• 3: Permanent or Total Disability
• 4: No Disability

DSB-07 · 235 · Product or Service ID Qualifier · Optional · Identifier (ID)

• DX: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
• ZZ: Mutually Defined

DSB-08 · 1137 · Diagnosis Code · Optional · String (AN) · Min 1 Max 15

2100 Detail > Member Level Detail Loop > Disability Information Loop > DTP

DTP Disability Eligibility Dates

Optional · Max use 2

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

• 360: Initial Disability Period Start
• 361: Initial Disability Period End

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Disability Eligibility Date · Required · String (AN) · Min 1 Max 35

2300 Health Coverage Loop Optional Max 99

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

HD Health Coverage

Required · Max use 1

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

• 001: Change
• 021: Addition
• 024: Cancellation or Termination

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

• DEN: Dental
• HLT: Health

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

DTP Health Coverage Dates

Required · Max use 6

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

• 303: Maintenance Effective
• 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 1 Max 35

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

REF Health Coverage Policy Number

Optional · Max use 14

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

• 1L: Group or Policy Number
• CE: Class of Contract Code
• X9: Internal Control Number

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

6880 Detail > Member Level Detail Loop > LS

LS Loop Header

Optional · Max use 1

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

2700 Member Reporting Categories Loop Optional Max >1

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

LX Member Reporting Categories

Required · Max use 1

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

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category Loop

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

N1 Reporting Category

Required · Max use 1

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

• 75: Participant

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

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

REF Reporting Category Reference

Optional · Max use 1

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

• 6M: Application Number
• 9X: Account Category
• 9V: Payment Category
• 17: Client Reporting Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN) · Min 1 Max 50

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

DTP Reporting Category Date

Optional · Max use 1

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

• 007: Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Member Reporting Category Effective Date(s) · Required · String (AN) · Min 1 Max 35

2750 Reporting Category Loop Optional Max 1

Variants (all may be used)

Reporting Category Loop

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

N1 Reporting Category

Required · Max use 1

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

• HU: Subsidiary

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

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

REF Reporting Category Reference

Optional · Max use 1

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

• 6M: Application Number
• 9X: Account Category
• 9V: Payment Category
• 17: Client Reporting Category

REF-02 · 127 · Member Reporting Category Reference ID · Required · String (AN) · Min 1 Max 50

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

DTP Reporting Category Date

Optional · Max use 1

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

• 007: Effective

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

• D8: Date Expressed in Format CCYYMMDD

DTP-03 · 1251 · Member Reporting Category Effective Date(s) · Required · String (AN) · Min 1 Max 35

6885 Detail > Member Level Detail Loop > LE

LE Loop Trailer

Optional · Max use 1

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

6900 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

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

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

GE Functional Group Trailer

Required · Max use 1

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

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

IEA Interchange Control Trailer

Required · Max use 1

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

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

EDI Samples

Dependent_ICHRA_Sample

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240105*1802*^*00501*000001566*1*P*:~
GS*BE*SENDER*RECEIVER*20240105*1802*5757*X*005010X220A1~
ST*834*74592441*005010X220A1~
BGN*00*74592441*20240105*202953*ET***2~
DTP*950*D8*20240101~
N1*P5*John Doe*FI*000000001~
N1*IN*Insure Co*FI*111111111~
N1*BO*Thatch*94*111111111~
INS*Y*18*021*EC*A***AC~
REF*0F*0000068929~
DTP*356*D8*20240101~
NM1*IL*1*Doe*John**34*000000000~
PER*IP**TE*5017622641***EM*john.doe@gmail.com~
N3*106 Test Trail~
N4*Hot Springs*AR*71913~
DMG*D8*19930101*F*M~
NM1*36*1*ACME INC~
PER*EP**TE*5555555555***EM*abc@employer.com~
N3*123 Main Street~
N4*Hot Springs*AR*71913*~
AMT*93*1000~
INS*N*01*021*EC*A~
REF*0F*0000068929~
DTP*EDL*D8*20240101~
NM1*IL*1*Cynthia*Kristina****34*000000001~
N3*106 Test Trail~
N4*Hot Springs*AR*71913~
DMG*D8*19890101*M*~
SE*27*74592441~
GE*1*5757~
IEA*1*000001566~

Subscriber_ICHRA_Sample

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240104*1802*^*00501*000001566*1*P*:~
GS*BE*SENDER*RECEIVER*20240105*1802*000005757*X*005010X220A1~
ST*834*74592441*005010X220A1~
BGN*00*74592441*20240104*202953*ET***2~
N1*P5*John Doe*FI*000000001~
N1*IN*Insure Co*FI*111111111~
N1*BO*Thatch*94*111111111~
INS*Y*18*021*EC*A***AC~
REF*0F*0000068929~
DTP*356*D8*20240101~
NM1*IL*1*Doe*John**34*000000000~
PER*IP**TE*5017622641***EM*john.doe@gmail.com~
N3*106 Test Trail~
N4*Hot Springs*AR*719137123~
DMG*D8*19930101*F*M~
NM1*36*1*Acme Inc~
PER*EP**TE*5555555555***EM*abc@employer.com~
N3*123 Main Street~
N4*Hot Springs*AR*71913*~
AMT*93*1000~
SE*19*74592441~
GE*1*000005757~
IEA*1*000001566~