ICHRA – Dependent Enrollment (FFE v7.0-based) (X220A1)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240105*1802*^*00501*000001566*1*P*>~
GS*BE*SENDER*RECEIVER*20240105*1802*000005757*X*005010X220A1~
ST*834*74592442*005010X220A1~
BGN*00*74592441*20240105*202953*ET***2~
DTP*007*D8*20240101~
N1*P5*John Doe*FI*000000001~
N1*IN*Acme Insurance*FI*111111111~
N1*BO*Thatch Health Insurance Services LLC*94*20782309~
INS*Y*18*021*EC*A***AC~
REF*0F*mbr_01jkh27m0m8teq05dq585gx3cr~
REF*17*prtpnt_01jkh27tgver1b0qgcre5jx7hd~
DTP*356*D8*20240101~
NM1*IL*1*Doe*John****34*000000000~
PER*IP**TE*5017622641***EM*john.doe@example.com~
N3*106 Test Trail~
N4*Hot Springs*AR*71913~
DMG*D8*19930202*M~
HLH*N~
NM1*36*2*Company Name~
PER*EP**TE*0123456789~
N4*City*CA*99999~
HD*021**HLT~
DTP*348*D8*20240101~
REF*1L*enrlmt_01jkh27cbxpdfa5aaner7vptbj~
REF*CE*99999CA020001001~
LS*2700~
LX*1~
N1*75*REQUEST SUBMIT TIMESTAMP~
REF*17*2023121413374163~
LX*2~
N1*75*SEP REASON~
REF*17*HR~
DTP*007*D8*20240101~
LX*3~
N1*75*PRE AMT TOT~
REF*9X*941.20~
DTP*007*D8*20240101~
LE*2700~
INS*N*01*021*EC*A~
REF*0F*mbr_01jkh27m0m8teq05dq585gx3cr~
REF*17*prtpnt_01jkh2bht7xwxztm0vv0wy46f1~
DTP*356*D8*20240101~
NM1*IL*1*Doe*Jane****34*111111111~
PER*IP**TE*5017621111***EM*jane.doe@example.com~
N3*106 Test Trail~
N4*Hot Springs*AR*71913~
DMG*D8*19930101*F~
HLH*N~
HD*021**HLT~
DTP*348*D8*20240101~
REF*1L*enrlmt_01jkh27cbxpdfa5aaner7vptbj~
REF*CE*99999CA020001001~
LS*2700~
LX*1~
N1*75*REQUEST SUBMIT TIMESTAMP~
REF*17*2023121413374163~
LX*2~
N1*75*SEP REASON~
REF*17*HR~
DTP*007*D8*20240101~
LE*2700~
SE*60*74592442~
GE*1*000005757~
IEA*1*000001566~

X12 834 ICHRA – Dependent Enrollment (FFE v7.0-based) (X220A1)