Delta Dental
Electronic Data Interchange
Transaction Set Implementation Guide
Health Care
Benefit Enrollment and
Maintenance
5010
834 Files
Function of 834 Files
Delta Dental prefers that full files are sent for eligibility. An 834 full file contains
members that are currently eligible on the sponsors system and additions,
terminations and changes for members that have incurred one of those activities
since the last full file was sent to the Delta Dental.
This guide contains the 834 segments, elements and their values that Delta Dental
requires to enroll and maintain member eligibility, as well as some optional
segments. All valid HIPAA 5010 segments, elements and values are accepted by
Delta Dental whether or not we use them. If HIPAA 5010 segments, elements and
values other than what are shown in our guide are necessary to enroll and maintain
member eligibility, it will have to be agreed upon by both parties prior to sending
files.
Delta Dental
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834 Benefit Enrollment and Maintenance
Usage
M
M
Loop
Repeat Repeat
0
None
0
None
Seg ID Name
Usage
Loop
Repeat Repeat
ST
BGN
Transaction Set Number
Beginning Segment
M
M
1
1
N1
LOOP ID – 1000A SPONSOR NAME
Sponsor Name
M
1
N1
LOOP ID – 1000B PAYER NAME
Payer Name
M
1
N1
LOOP ID – 1000C TPA/BROKER NAME
TPA/Broker Name
C
1
Seg ID Name
ISA
Interchange Control Header
GS
Functional Group Header
Table 1 - Header
None
None
1
1
1
Table 2 – Detail
INS
REF
REF
REF
REF
REF
DTP
DTP
LOOP ID – 2000 MEMBER LEVEL DETAIL
Member Level Detail
Member SSN
Member Group Number
Member Subgroup ID
Member CAID
Member Carrier ID
Eligibility End Date
Employment Date
M
M
C
C
C
C
C
C
Loop
Repeat Repeat
>1
1
1
1
1
1
1
1
1
NM1
N3
N4
DMG
LOOP ID – 2100A MEMBER NAME DETAIL
Member Name
Member Street Address
Member City, State, ZIP Code
Member Demographic Information
M
M
M
M
1
1
1
1
NM1
LOOP ID – 2100B INCORRECT MEMBER NAME
Member Name
C
1
NM1
LOOP ID – 2100G RESPONSIBLE PERSON
Responsible Person Name
O
1
HD
DTP
DTP
REF
REF
LOOP ID – 2300 HEALTH COVERAGE
Health Coverage
Benefit Begin
Benefit End
Benefit Group Number
Benefit Subgroup ID
M
C
C
C
C
1
1
1
1
1
SE
Transaction Set Trailer
M
1
Seg ID Name
Delta Dental
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Usage
1
1
1
1
GE
IEA
Functional Group Trailer
Interchange Control Trailer
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M
M
1
1
None
None
ISA – Interchange Control Header
Usage
: Mandatory
Segment Max Use
Within Loop
: 1
Loop Repeat
: NONE
Loop ID
: NONE
Example:
ISA*00*bbbbbbbbbb*00*bbbbbbbbbb*01*123456789bbbbbb*01*567890123bbbbbb*120101*1452*U*00501*
000000001*0*P*:~
Note b = blank
Segment Usage Name
Values Description
ISA01
M
Authorization Information Qualifier “00”
No Authorization information present.
ISA02
10/10
M
Authorization Information
Element should consist of 10 spaces
ISA03
M
Security Info Qualifier
ISA04
10/10
M
Security Info
ISA05
M
Sender Interchange ID Qualifier
ISA06
M
ISA07
“00”
No Security info present.
Min/Max
Length
2/2
2/2
Element should consist of 10 spaces
“01”
“ZZ”
Duns (Dun & Bradstreet)
Mutually Defined
2/2
Interchange Sender ID
Element must be space filled to the right
To a length of 15
15/15
M
Receiver Interchange ID Qualifier “01”
Duns (Dun & Bradstreet)
Mutually Defined
2/2.
ISA08
M
Interchange receiver ID
ISA09
M
Interchange Date
YYMMDD
6/6
ISA10
M
Interchange Time
HHMM
4/4
ISA11
M
Repetition Separator
U.S. EDI Community of ASC X12,
TDCC, and UCS
1/1
ISA12
M
Interchange control Version
“00501”
5/5
ISA13
M
Interchange control number
9 digit control number must match the
control number of the IEA02 element
9/9
ISA14
M
Acknowledgment Requested
“0”
No Acknowledgment Requested
1/1
ISA15
M
Usage Indicator
Production
Test
1/1
ISA16
M
Component element separator
“P”
“T”
“: “
See Duns in Supplement
“^”
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15/15
1/1
GS – Functional Group Header
Usage
: Mandatory
Segment Max Use
Within Loop
: 1
Loop Repeat
: NONE
Loop ID
: NONE
Example:
GS*BE*123456789*567890123*20120101*1452*000000001*X*005010X220~
Min/Max
Length
Segment Usage Name
Values Description
GS01
M
Functional Identifier Code
“BE”
GS02
M
Application Senders Code
GS03
M
Application Receiver’s Code
GS04
M
Date
CCYYMMDD
8/8
GS05
M
Time
HHMM
4/4
GS06
M
Group Control Number
Must match the control number of the
GE02 element
1/9
GS07
M
Responsibility Agency Code
Accredited Standards Committee X12
1/2
GS08
M
Version/Release/Industry Identifier
Code
“005010X220”
1/12
Benefit Enrollment and Maintenance
2/2.
Senders ID
2/15
See Duns in Supplement
“X”
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2/15
ST – Transaction Set Header
Usage
: Mandatory
Segment Max Use
Within Loop
: 1
Loop Repeat
: NONE
Loop ID
: NONE
Example:
ST*834*0001~
Segment Usage Name
Values Description
ST01
M
Transaction Set Identifier Code
“834”
ST02
M
Transaction Set Control Number
Min/Max
Length
Eligibility coverage or benefit inquiry
3/3
Identifying control number that must be
unique within the transaction set functional
group assigned by the originator for a
transaction set.
4/9
COMMENT: The transaction set control numbers in ST02 and SE02 must be identical. This
unique number also aids in error resolution research. Start with the number, for example “0001”,
and increment from there. This number must be unique within the specific group and interchanges,
but can repeat in other groups and interchanges.
ST03
M
Implementation Convention
Reference
“005010X220”
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1/35
BGN – Beginning Segment
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
NONE
NONE
Example:
BGN*00*54321*20120101*1200****RX~
Segment Usage Name
Values Description
“00”
Min/Max
Length
Original Transmission
BGN01
M
Purpose Code
BGN02
M
Reference Number
BGN03
M
Date
CCYYMMDD
8/8
BGN04
M
Time
HHMMSSUU/ HHMMSS/ HHMM
4/8
1/50
BGN05
NOT USED
BGN06
NOT USED
BGN07
NOT USED
BGN08
BGN09
M
Action Code
2/2
“RX”
“2”
“4”
Full enrollment with adds, terms and changes
Changes only./Update
Audit
1/2
NOT USED
COMMENT: Files with an Action Code of “4” (Audit) should contain all active members, no
changes or terminations. Audits should be sent periodically for groups that send update files on a
regular basis.
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N1 – Name (Sponsor)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
1000A
Example:
N1*P5*ABC CORPORATION*FI*919191919~
Segment Usage Name
Values Description
N101
M
Entity Identifier Code
“P5”
N102
M
Name
N103
M
Identifier Code
N104
M
Identifier
“FI”
“ZZ”
Plan Sponsor
2/2
Group Name
01/35
Fed Tax ID
Mutually Defined
2/2
Organizational ID
2/80
N105
NOT USED
N106
NOT USED
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Min/Max
Length
N1 – Name (Payer)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
1000B
Example:
N1*IN*Delta Dental *FI*987654321~
Min/Max
Length
Segment Usage Name
Values Description
N101
M
Entity Identifier Code
“IN”
N102
M
Name
See Name in Supplement
29/29
N103
M
Identifier Code
“FI”
2/2
N104
M
Identifier
See Federal Tax ID in Supplement
Insurer
Fed Tax ID
N105
NOT USED
N106
NOT USED
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2/2
2/80
N1 – Name (TPA/Broker Name)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional
1
1
1000C
Example:
N1*TV*XYZ Processing*FI*999999999~
Segment Usage Name
Values Description
N101
M
Entity Identifier Code
“BO”
“TV”
N102
M
Name
N103
M
Identifier Code
N104
M
Identifier
“94”
“FI”
“XV”
Broker/ Sales Office
Third Party Administrator(TPA)
2/2
TPA/Broker Name
1/60
Organization Code
Fed Tax ID
HFCA Plan ID
2/2
Organizational ID
2/80
N105
NOT USED
N106
NOT USED
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Min/Max
Length
INS – Insured Benefit (Subscriber or Dependent)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
>1
2000
Example:
INS*Y*18*021**A~
INS*N*19*001*AI*A****F~
INS*N*19*001*AI*A*****Y~
Segment Usage Name
Values Description
INS01
M
Yes/No Condition
“Y”
“N”
INS02
M
Individual Relationship Code
INS03
M
INS04
Min/Max
Length
Subscriber
Dependent
1/1
“01”
“09”
“18”
“19”
“25”
“53”
Spouse
Adopted Child
Self
Child
Ex-Spouse
Life Partner
2/2
Maintenance Type Code
“001”
“021”
“024”
“030”
Change
Addition
Termination
Audit/No Change
3/3
O
Maintenance Reason Code
“03”
“04”
“11”
“AI”
Death
Retirement
Surviving Spouse
No Reason Given
2/2
INS05
M
Benefit Status Code
“A”
“C”
“S”
Active
COBRA
Surviving Spouse
1/1
INS06
O
Medicare Plan Code
“A”
“B”
“C”
“D”
“E”
Medicare Part A
Medicare Part B
Medicare Part A and B
Medicare
No Medicare
1/1
INS07
NOT USED
INS08
O
Employment Status Code
“RT”
Retired
2/2
INS09
O
Student Status Code
“F”
“N”
“P”
Full-time
Not a Student
Part-time
1/1
INS10
O
Handicap Status Indicator
“Y”
“N”
Yes, handicapped
No, not handicapped
1/1
INS11
INS12
NOT USED
NOT USED
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INS13
INS14
INS15
INS16
INS17
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
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REF – Reference Identification (Subscriber SSN)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
2000
Example:
REF*0F*999887777~
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“0F”
REF02
M
Reference Identification
Min/Max
Length
Subscriber Number Qualifier
2/2
Subscriber Social Security Number
9/9
COMMENT: The social security must be 9 numeric digits. Alpha characters are not expected
within the social security number REF02 element.
REF03
NOT USED
REF04
NOT USED
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REF – Reference Identification (Subscriber Group Number)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (This segment is required if the REF*1L segment is not sent in the HD loop)
1
1
2000
Example:
REF*1L*0005555~ (this is group number only)
REF*1L*00055550001~ (this is group and subgroup number)
REF*1L*0005555_0001~ (this is group and subgroup number)
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“1L”
REF02
M
Reference Identification
Min/Max
Length
Group Number
2/2
Group Number
7/12
COMMENT: The Group number must be 7 numeric digits. Alpha characters are not expected
within the group number REF02 element. Your Group Administration analyst will furnish you
with the group number(s).
COMMENT: The subgroup number may also be concatenated to the end of the group number or
delimited with an agreed upon character (other than the three characters already being used for the
segment terminator, element separator, repetition separator and sub-element separator) which
separates the group and subgroup number.
REF03
NOT USED
REF04
NOT USED
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REF – Reference Identification (Subscriber Subgroup Number)
Usage
: Conditional (This segment is required if the REF*17 segment is not sent in the HD loop)
(The Subgroup number may also be sent on the REF*1L group number seg)
Segment Max Use
Within Loop
: 1
Loop Repeat
: 1
Loop ID
: 2000
Example:
REF*17*0001~
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“17”
REF02
M
Reference Identification
Min/Max
Length
Client Reporting Category
2/2
Subgroup Number
4/5
COMMENT: Alpha characters are not expected within the subgroup number REF02 element.
Your Group Administration analyst will furnish you with the subgroup number(s).
REF03
NOT USED
REF04
NOT USED
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REF – Reference Identification (CAID)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2000
Example:
REF*23*987654321012345~
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“23”
REF02
M
Reference Identification
Customer Alternate ID
Min/Max
Length
Client Number
COMMENT: The Customer Alternate ID must be no more than 15 numeric digits. Alpha
characters are not expected within the Customer Alternate ID REF02 element.
REF03
NOT USED
REF04
NOT USED
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2/2
9/18
REF – Reference Identification (Subscriber Carrier ID)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2000
Example:
REF*DX*DDP~
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“DX”
REF02
M
Reference Identification
See Carrier ID in Supplement
Department/Agency Number
REF03
NOT USED
REF04
NOT USED
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Min/Max
Length
2/2
4/6
DTP – Member Level Dates (Eligibility End)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2000
Example:
DTP*357*D8*20120101~
Segment Usage Name
Values Description
DTP01
M
Date/Time Qualifier
“357”
DTP02
M
DTP03
M
Min/Max
Length
Eligibility End
3/3
Date Time Period Format Qualifier “D8”
Date Format CCYYMMDD
2/2
Date
Eligibility End Date
8/8
COMMENT: If a termination is being sent and a 2300 loop is not provided with a benefit end
date, this segment date is required. If a benefit end date is provided in the 2300 loop, the term date
in the 2000 will be ignored. If a coverage is not specified in a 2300 loop, the termination date in
the 2000 loop will be for all coverages.
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DTP – Member Level Dates (Employment Date/Hire Date)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2000
Example:
DTP*336*D8*19980301~
Segment Usage Name
Values Description
DTP01
M
Date/Time Qualifier
“336”
DTP02
M
DTP03
M
Min/Max
Length
Employment Begin
3/3
Date Time Period Format Qualifier “D8”
Date Format CCYYMMDD
2/2
Date
Hire Date
8/8
COMMENT: Segment is not sent for non-subscriber INS loops.
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NM1 – Member Name (Subscriber or Dependent Name and SSN)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
2100A
Example:
NM1*IL*1*DOE*JOHN*MAYNARD***34*111223333~
Min/Max
Length
Segment Usage Name
Values Description
NM101
M
Entity Identifier Code
“IL”
“74”
Subscriber / Dependent
Corrected Insured
2/2
NM102
M
Entity Type Qualifier
“1”
Person (signifies this is a person)
1/1
NM103
M
Last Name
1/24
NM104
M
First Name
1/24
NM105
O
Middle Name
1/24
NM106
NOT USED
NM107
NOT USED
NM108
O
Identification Code Qualifier
NM109
O
Identification Code
“34”
SSN Qualifier
2/2
Individual SSN
9/9
COMMENT: The social security number must be 9 numeric digits. Alpha characters are not
expected within the social security number NM109 element.
NM110
NOT USED
NM111
NOT USED
NM112
NOT USED
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N3 – Address Information (Subscriber Address)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
2100A
Example:
N3*123 ANY STREET*APT A~
Segment Usage Name
Values Description
Min/Max
Length
N301
M
Address Information
Address Line 1
1/30
N302
O
Address Information
Address Line 2
1/30
COMMENT: The segment is mandatory for subscribers and optional for dependents.
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N4 – Geographic Location (Subscriber City, State, Zip)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
2100A
Example:
N4*ANY CITY*MI*444449999~
N4*TORONTO*ON*M2J4V2*CAN~
Segment Usage Name
Values Description
Free Form Text of City
Min/Max
Length
N401
M
City Name
2/30
N402
O
State or Province Code
Code (Standard State/Province) as defined
by appropriate government agency.
See Appendix A.
COMMENT: N402 is required if the address is US or Canada.
2/2
N403
M
Postal Code
Zip Code
5/9
N404
O
Country Code
Code from ISO 3166
3/3
COMMENT: N404 is required if the N3 and N4 segments designate a foreign address.
N405
O
Location Qualifier
N406
O
N407
O
“CY”
County/Parish
2/2
Location Identifier
County code
2/3
Country Subdivision Code
Code from Part 2 of ISO 3166
2/3
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DMG – Demographic Information (Subscriber or Dependent)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
2100A
Example:
DMG*D8*19840713*M~
Segment Usage Name
Values Description
Min/Max
Length
DMG01
M
Date Time Period Format Qualifier “D8”
Date Format CCYYMMDD
2/2
DMG02
M
Date
Birth Date
8/8
DMG03
M
Gender Code
Female
Male
Unknown
1/1
“F”
“M”
“U”
DMG04
NOT USED
DMG05
NOT USED
DMG06
NOT USED
DMG07
NOT USED
DMG08
NOT USED
DMG09
NOT USED
DMG10
NOT USED
DMG11
NOT USED
COMMENT: The segment is mandatory for subscribers and dependents.
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NM1 – Incorrect Member Name (Subscriber or Dependent Name
and SSN)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (Only required by DDMI if the Subscriber SSN is being changed)
1
1
2100B
Example:
NM1*70*1*DOE*JOHN*MAYNARD***34*999887777~
COMMENT: This segment should only be sent if the subscriber’s SSN is being changed. The
prior incorrect SSN is sent on the NM109 element. This segment should only be sent on the
subscriber INS loop.
Min/Max
Length
Segment Usage Name
Values Description
NM101
M
Entity Identifier Code
“70”
Prior Incorrect Insured
2/2
NM102
M
Entity Type Qualifier
“1”
Person (signifies this is a person)
1/1
NM103
M
Last Name
1/24
NM104
M
First Name
1/24
NM105
O
Middle Name
1/24
NM106
NOT USED
NM107
NOT USED
NM108
M
Identification Code Qualifier
NM109
M
Identification Code
“34”
SSN Qualifier
2/2
Individual SSN
9/9
NM110
NOT USED
NM111
NOT USED
NM112
NOT USED
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NM1 – Responsible Person (OBRA)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional
1
1
2100B
Example:
NM1*E1*1*DOE*JOHN*MAYNARD***34*999887777~
COMMENT: Used to identify the person other than the subscriber responsible for a child.
Min/Max
Length
Segment Usage Name
Values Description
NM101
M
Entity Identifier Code
“E1”
QMSCO/OBRA
2/2
NM102
M
Entity Type Qualifier
“1”
Person (signifies this is a person)
1/1
NM103
M
Last Name
1/24
NM104
M
First Name
1/24
NM105
O
Middle Name
1/24
NM106
NOT USED
NM107
NOT USED
NM108
M
Identification Code Qualifier
NM109
M
Identification Code
“34”
SSN Qualifier
2/2
Individual SSN
9/9
NM110
NOT USED
NM111
NOT USED
NM112
NOT USED
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HD – Health Coverage
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2300
Example:
HD*021**DEN~
HD*001**DEN*30*FAM~
Segment Usage Name
Values Description
HD01
“001”
“021”
“024”
“030”
M
HD02
Maintenance Type Code
Min/Max
Length
Change
Addition
Cancellation or Termination
No change
3/3
NOT USED
HD03
M
Insurance Line Code
HD04
O
Plan Coverage Desc
“DEN” Dental
3/3
Group Program Type
2/50
COMMENT: HD04 is only required if the Group contract allows for Multiple Program Types.
Your Group Administration analyst will furnish you with the Program Type(s) if necessary.
HD05
O
Coverage Level Detail
“E1D”
“E5D”
“EMP”
“ESP”
“FAM”
Employee and 1 dependent
Employee and more than 1 dependent
Employee Only
Employee and Spouse
Employee, Spouse, and dependent(s)
3/3
COMMENT: HD05 is only required if the Group contract allows for Family Type Groups.
HD06
NOT USED
HD07
NOT USED
HD08
NOT USED
HD09
O
Late Enrollment Indicator
HD10
NOT USED
HD11
NOT USED
“Y”
“N”
Late enrollee
Regular enrollee
1/1
COMMENT: The HD segment is required when adding coverage (INS code 021). For Full Files
an HD segment is required for all employees not being terminated. The HD segment is optional
for terminations if an Eligibility End Date was supplied in the 2000 loop.
Delta Dental
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Electronic Data Interchange 834 Mapping Version 005010
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DTP – Member Level Dates (Benefit Begin)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2300
Example:
DTP*348*D8*20120101~
Segment Usage Name
Values Description
DTP01
M
Date/Time Qualifier
“348”
DTP02
M
DTP03
M
Min/Max
Length
Benefit Begin
3/3
Date Time Period Format Qualifier “D8”
Date Format CCYYMMDD
2/2
Date
Benefit Begin Date
8/8
COMMENT: Segment is required if HD01 = “021” or “030”
Delta Dental
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DTP – Member Level Dates (Benefit End)
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Conditional (see comment)
1
1
2300
Example:
DTP*349*D8*20120201~
Segment Usage Name
Values Description
DTP01
M
Date/Time Qualifier
“349”
DTP02
M
DTP03
M
Min/Max
Length
Benefit End
3/3
Date Time Period Format Qualifier “D8”
Date Format CCYYMMDD
2/2
Date
Benefit End Date
8/8
COMMENT: Segment is required if HD01 = “024”
COMMENT: DTP03 should be the last date of actual coverage
Delta Dental
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REF – Health Coverage Policy (Subscriber Group Number)
Usage : Conditional (This segment is required if the REF*1L segment is not sent in the INS loop)
Segment Max Use
Within Loop
: 1
Loop Repeat
: 1
Loop ID
: 2300
Example:
REF*1L*0005555~ (this is group number only)
REF*1L*00055550001~ (this is group and subgroup number)
REF*1L*0005555_0001~ (this is group and subgroup number)
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“1L”
REF02
M
Reference Identification
Min/Max
Length
Group Number
2/2
Group Number
7/12
COMMENT: The Group number must be 7 numeric digits. Alpha characters are not expected
within the group number REF02 element.
REF03
REF04
COMMENT: The subgroup number may also be concatenated to the end of the group number or
delimited with an agreed upon character which separates the group and subgroup number.
NOT USED
NOT USED
Delta Dental
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REF – Health Coverage Policy (Subscriber Subgroup Number)
Usage
: Conditional (This segment is required if the REF*17 segment is not sent in the INS loop)
(The subgroup number may also be sent on the REF*1L group number seg)
Segment Max Use
Within Loop
: 1
Loop Repeat
: 1
Loop ID
: 2300
Example:
REF*17*0001~
Segment Usage Name
Values Description
REF01
M
Reference ID Qualifier
“17”
REF02
M
Reference Identification
Min/Max
Length
Client Reporting Category
2/2
Subgroup Number
4/5
COMMENT: Alpha characters are not expected within the subgroup number REF02 element.
Your Group Administration analyst will furnish you with the subgroup number(s).
REF03
NOT USED
REF04
NOT USED
Delta Dental
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SE – Transaction Set Trailer
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
NONE
NONE
Example:
SE*19*12345~
Segment Usage Name
Values Description
Min/Max
Length
SE01
M
Number of Segments Included
Total number of segments included in a
transaction set including ST and SE
1/10
SE02
M
Transaction Set Control Number
4 to 9 digit control number.
Must match Transaction Set Control
Number in ST02.
4/9
Delta Dental
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GE – Functional Group Trailer
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
NONE
Example:
GE*1*000000001~
Segment Usage Name
Values Description
Min/Max
Length
GE01
M
Number of Transaction
Total number of transaction sets included in
the functional group.
1/6
GE02
M
Transaction Set Control Number
1 to 9 digit control number. Must match
Functional Group Control Number in GS06.
1/9
Delta Dental
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IEA – Interchange Control Trailer
Usage
:
Segment Max Use
Within Loop
:
Loop Repeat
:
Loop ID
:
Mandatory
1
1
NONE
Example:
IEA*1*000000001*~
Segment Usage Name
Values Description
Min/Max
Length
IEA01
M
Number of Included Functional Groups
Total number of functional groups included
in the Interchange.
1/5
IEA02
M
Interchange Control Number
9 digit control number. Must match
Interchange Control Number in ISA13.
9/9
Delta Dental
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Electronic Data Interchange 834 Mapping Version 005010
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834 Full File Transaction Example
Scenario #1
Company 1 is sending a full file of all covered Subscribers and dependents. For purposes of this example, company
1 has 1 employee with a spouse. Also, a dependent is being terminated under that 1 employee.
Sown in the example is the following;
Subscriber is John Paul Doe, DOB June 10 1940, SSN = 111223333, benefit begin Date for Eligibility is
August 1 1989
Spouse is Jane M Doe, DOB July 15 1945, SSN=111224444, benefit begin Date for Eligibility is March 1
1999
Dependent Mark Doe is being terminated effective July 1, 2002
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*120101*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*201201011*0916*2304*X*005010X220~
ST*834*12345~
BGN*00*ABCDE12456*20000815*0100****RX~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*021**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19890801~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
HD*021**DEN~
DTP*348*D8*19890801~
INS*N*01*021**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
NM1*IL*1*DOE*JANE*M***34*111224444~
DMG*D8*19450715*F~
HD*021**DEN~
DTP*348*D8*19990301~
INS*N*01*024**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
NM1*IL*1*DOE*MARK****34*333224444~
DMG*D8*19790515*M~
HD*024**DEN~
DTP*349*D8*20020701~
SE*35*12345~
GE*1*2304~
IEA*1*000000745~
Delta Dental
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834 Maintenance Transaction Examples
Scenario #1
Add a Subscriber and Spouse
Subscriber is John P Doe, DOB June 10 1940, SSN = 111223333
Spouse is Jane M Doe, DOB July 15 1945, SSN=111224444
Benefit begin Date for both is is May 1 1996
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*021**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
HD*021**DEN~
DTP*348*D8*19960501~
INS*N*01*021**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
NM1*IL*1*DOE*JANE*M***34*111224444~
DMG*D8*19450715*F~
HD*021**DEN~
DTP*348*D8*19960501~
SE*26*12345~
GE*1*2304~
IEA*1*000000745~
Delta Dental
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834 Maintenance Transaction Examples (cont’d)
Scenario #2
Terminate Subscriber with a benefit end date of May 1, 2002
Subscriber is John P Doe, DOB June 10 1940, SSN = 111223333
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*024**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
HD*024**DEN~
DTP*349*D8*20020501~
SE*17*12345~
GE*1*2304~
IEA*1*000000745~
Termination without sending an HD would also be valid as shown below (this would terminate all insurance
coverages i.e. dental, vision, medical):
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*024**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
DTP*357*D8*20020501~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
SE*16*12345~
GE*1*2304~
IEA*1*000000745~
Delta Dental
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Electronic Data Interchange 834 Mapping Version 005010
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834 Maintenance Transaction Examples (cont’d)
Scenario #3
Change the Group and Subgroup to which a subscriber belongs.
This will require a Termination of the Subscriber and Add of the Subscriber.
Subscriber is John P Doe, DOB June 10 1940, SSN = 111223333.
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*024**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
HD*024**DEN~
DTP*349*D8*20020501~
INS*Y*18*021**A~
REF*0F*111223333~
REF*1L*0006666~
REF*17*0002~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 Any St*Apt.A~
N4*Any Town*MI*48111~
DMG*D8*19400610*M~
HD*021**DEN~
DTP*348*D8*20020501~
SE*29*12345~
GE*1*2304~
IEA*1*000000745~
Delta Dental
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Electronic Data Interchange 834 Mapping Version 005010
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834 Maintenance Transaction Examples (cont’d)
Scenario #4
Subscriber is John P Doe, DOB June 10 1940, SSN = 111223333 has moved his residence to a new location
ISA*00*
*00*
*ZZ*067999979
*01*5678901234
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*5678901234*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*001**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 THAT ST*APT.B~
N4*THAT TOWN*MI*4899~
DMG*D8*19400610*M~
HD*001**DEN~
DTP*303*D8*20020501~
SE*17*12345~
GE*1*2304~
IEA*1*000000745~
Change without sending an HD would also be valid as shown below (this would change all insurance
coverages i.e. dental, vision, medical):
ISA*00*
*00*
*ZZ*067999979
*01*076334622
*000821*0915*^*00501*000000745*0*P*>~
GS*BE*C1591*076334622*20020821*0916*2304*X*005010X220~
ST*834*12345*005010X220~
BGN*00*ABCDE12456*20000815*0100****2~
N1*P5*ABC CORP*FI*777777777~
N1*IN*DELTA DENTAL*FI*123456789~
INS*Y*18*001**A~
REF*0F*111223333~
REF*1L*0005555~
REF*17*0001~
REF*DX*DDPM~
DTP*336*D8*19960301~
NM1*IL*1*DOE*JOHN*PAUL***34*111223333~
N3*100 THAT ST*APT.B~
N4*THAT TOWN*MI*4899~
DMG*D8*19400610*M~
SE*15*12345~
GE*1*2304~
IEA*1*000000745~
Delta Dental
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APPENDIX A
US STATE/TERRITORY CODES
AK - ALASKA
AL – ALABAMA
AR – ARKANSAS
AS – AMERICAN SAMOA
AZ – ARIZONA
CA – CALIFORNIA
CO – COLORADO
CT – CONNECTICUT
DC – DISTRICT OF COLUMBIA
DE – DELAWARE
FL - FLORIDA
FM – MICRONESIA
GA – GEORGIA
GU – GUAM
HI – HAWAII
IA – IOWA
ID – IDAHO
IL – ILLINOIS
IN – INDIANA
KS – KANSAS
KY – KENTUCKY
LA – LOUISIANA
MA – MASSACHUSETTS
MD – MARYLAND
ME – MAINE
MH – MARSHALL ISLANDS
MI – MICHIGAN
MN – MINNESOTA
MO – MISSOURI
MP – NORTHERN MARIANA ISLANDS
MS – MISSISSIPPI
MT – MONTANA
NC – NORTH CAROLINA
ND – NORTH DAKOTA
NE – NEBRASKA
NH – HEW HAMPSHIRE
NJ – NEW JERSEY
NM – NEW MEXICO
NV – NEVADA
NY – NEW YORK
OH – OHIO
OK – OKLAHOMA
OR – OREGON
PA – PENNSYLVANIA
PR – PUERTO RICO
PW – PALAU
RI – RHODE ISLAND
SC – SOUTH CAROLINA
SD – SOUTH DAKOTA
TN – TENNESSEE
TX – TEXAS
UT – UTAH
VA – VIRGINIA
VI – VIRGIN ISLANDS
VT – VERMONT
WA – WASHINGTON
WI – WISCONSIN
WV – WEST VIRGINIA
WY – WYOMING
Delta Dental
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Electronic Data Interchange 834 Mapping Version 005010
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APPENDIX A(continued)
CANADIAN PROVINCE CODES
AB – ALBERTA
BC – BRITISH COLUMBIA
LB – LABRADOR
MB – MANITOBA
NB – BRUNSWICK
NF – NEWFOUNDLAND
NS – NOVA SCOTIA
NT – NORTHWEST TERRITORIES
ON – ONTARIO
PE – PRINCE EDWARD ISLAND
QC – QUEBEC
SK – SASKATCHEWAN
YT – YUKON TERRITORY
Delta Dental
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