834 Benefit Enrollment
and Maintenance 5010
HIPAA/V5010X220/834: 834 Benefit Enrollment
and Maintenance
Companion Guide Version 1.0
COPYRIGHT © Blue Cross of Idaho, 2008. All Rights Reserved.
5/11/2011
Benefit Enrollment and Maintenance - 834
Table of Contents
834
Benefit Enrollment and Maintenance .......................................................................................................................... 1
ISA
Interchange Control Header .................................................................................................................................... 4
GS
Functional Group Header ........................................................................................................................................ 7
ST
Transaction Set Header ............................................................................................................................................ 9
BGN
Beginning Segment ................................................................................................................................................. 10
REF
Transaction Set Policy Number ............................................................................................................................. 12
DTP
File Effective Date ................................................................................................................................................... 13
1000A
Loop Sponsor Name ................................................................................................................................................ 14
N1
Sponsor Name ......................................................................................................................................................... 15
1000B
Loop Payer .............................................................................................................................................................. 16
N1
Payer ........................................................................................................................................................................ 17
1000C
Loop TPA/Broker Name ........................................................................................................................................ 18
N1
TPA/Broker Name .................................................................................................................................................. 19
1100C
Loop TPA/Broker Account Information ............................................................................................................... 20
ACT
TPA/Broker Account Information ........................................................................................................................ 21
2000
Loop Member Level Detail..................................................................................................................................... 22
INS
Member Level Detail .............................................................................................................................................. 23
REF
Subscriber Identifier ............................................................................................................................................... 28
REF
Member Policy Number ......................................................................................................................................... 29
REF
Member Supplemental Identifier .......................................................................................................................... 30
DTP
Member Level Dates ............................................................................................................................................... 32
2100A
Loop Member Name ............................................................................................................................................... 34
NM1
Member Name ......................................................................................................................................................... 35
PER
Member Communications Numbers ..................................................................................................................... 37
N3
Member Residence Street Address ........................................................................................................................ 39
N4
Member City, State, ZIP Code .............................................................................................................................. 40
DMG
Member Demographics .......................................................................................................................................... 42
EC
Employment Class .................................................................................................................................................. 45
2300
Loop Health Coverage ............................................................................................................................................ 47
HD
Health Coverage ...................................................................................................................................................... 48
DTP
Health Coverage Dates ........................................................................................................................................... 50
AMT
Health Coverage Policy .......................................................................................................................................... 51
REF
Health Coverage Policy Number ........................................................................................................................... 52
REF
Prior Coverage Months .......................................................................................................................................... 53
2310
Loop Provider Information .................................................................................................................................... 54
LX
Provider Information ............................................................................................................................................. 55
NM1
Provider Name ........................................................................................................................................................ 56
N3
Provider Address .................................................................................................................................................... 58
N4
Provider City, State, ZIP Code .............................................................................................................................. 59
PER
Provider Communications Numbers ..................................................................................................................... 60
PLA
Provider Change Reason ........................................................................................................................................ 62
2320
Loop Coordination of Benefits ............................................................................................................................... 63
COB
Coordination of Benefits......................................................................................................................................... 64
REF
Additional Coordination of Benefits Identifiers ................................................................................................... 65
DTP
Coordination of Benefits Eligibility Dates ............................................................................................................ 66
2330
Loop Coordination of Benefits Related Entity ..................................................................................................... 67
NM1
Coordination of Benefits Related Entity ............................................................................................................... 68
N3
Coordination of Benefits Related Entity Address ................................................................................................ 69
N4
Coordination of Benefits Other Insurance Company City, State, ZIP Code ..................................................... 70
PER
Administrative Communications Contact ............................................................................................................ 71
2500
Loop Flexible Spending Account ........................................................................................................................... 72
FSA
Flexible Spending Account ..................................................................................................................................... 73
AMT
Monetary Amount Information ............................................................................................................................. 76
DTP
Date or Time or Period ........................................................................................................................................... 77
REF
Reference Information............................................................................................................................................ 78
LS
Loop Additional Reporting Categories ................................................................................................................. 79
LS
Additional Reporting Categories ........................................................................................................................... 80
2700
Loop Member Reporting Categories ..................................................................................................................... 81
ii
Benefit Enrollment and Maintenance - 834
LX
2750
N1
REF
DTP
LE
SE
GE
IEA
Member Reporting Categories .............................................................................................................................. 82
Loop Reporting Category ....................................................................................................................................... 83
Reporting Category ................................................................................................................................................ 84
Reporting Category Reference .............................................................................................................................. 85
Reporting Category Date ....................................................................................................................................... 86
Additional Reporting Categories Loop Termination ........................................................................................... 87
Transaction Set Trailer .......................................................................................................................................... 88
Functional Group Trailer ....................................................................................................................................... 89
Interchange Control Trailer .................................................................................................................................. 90
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Benefit Enrollment and Maintenance - 834
834
Benefit Enrollment and Maintenance
Functional Group=BE
Purpose: This X12 Transaction Set contains the format and establishes the data contents of the Benefit Enrollment and
Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment. This
transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such
transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of this standard, the sponsor
is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government
agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or
benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization
(PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former
groups. For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data
gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.
Not Defined:
Pos
Id
ISA
GS
Segment Name
Interchange Control Header
Functional Group Header
Req
M
M
Max Use
1
1
Repeat
Notes
Usage
Required
Required
Id
ST
BGN
REF
Segment Name
Transaction Set Header
Beginning Segment
Transaction Set Policy
Number
File Effective Date
Req
M
M
O
Max Use
1
1
1
Repeat
Notes
Usage
Required
Required
Situational
O
>1
1
N1/0700L
N1/0700
Required
N1/0700L
N1/0700
Required
N1/0700L
N1/0700
Situational
Heading:
Pos
0100
0200
0300
0400
DTP
LOOP ID - 1000A
0700
N1
Sponsor Name
M
1
LOOP ID - 1000B
0700
N1
Payer
M
1
O
1
LOOP ID - 1000C
0700
N1
TPA/Broker Name
LOOP ID - 1100C
1200
ACT
TPA/Broker Account
Information
Situational
1
2
1
O
1
Req
Max Use
O
M
O
O
1
1
1
13
O
24
Situational
Detail:
Pos
Id
LOOP ID - 2000
0100
INS
0200
REF
0200
REF
0200
REF
Segment Name
Member Level Detail
Subscriber Identifier
Member Policy Number
Member Supplemental
Identifier
Member Level Dates
0250
DTP
LOOP ID - 2100A
0300
NM1
Member Name
0400
PER
Member Communications
Numbers
0500
N3
Member Residence Street
Address
0600
N4
Member City, State, ZIP Code
0800
DMG Member Demographics
Repeat
>1
Notes
N2/0100L
N2/0100
N2/0200
N2/0200
N2/0200
Usage
Required
Required
Situational
Situational
Situational
1
O
O
1
1
Required
Situational
O
1
Situational
O
O
1
1
Required
Situational
1
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1000
Benefit Enrollment and Maintenance - 834
EC
LOOP ID - 2300
2600
HD
2700
DTP
2800
AMT
2900
REF
2900
REF
LOOP ID - 2310
3100
LX
3200
NM1
3500
N3
3600
N4
3700
PER
3950
PLA
LOOP ID - 2320
4000
COB
4050
REF
4070
DTP
LOOP ID - 2330
4100
NM1
4300
N3
4400
N4
4500
PER
LOOP ID - 2500
5500
FSA
5600
AMT
5700
DTP
5750
REF
LOOP ID - LS
6880
LS
LOOP ID - 2700
6881
LX
LOOP ID - 2750
6882
N1
6883
REF
6884
DTP
6885
LE
6900
SE
Employment Class
O
>1
Health Coverage
Health Coverage Dates
Health Coverage Policy
Health Coverage Policy
Number
Prior Coverage Months
O
O
O
O
1
6
9
14
O
1
Situational
99
Situational
Required
Situational
Situational
Situational
30
N2/3100L
N2/3100
N2/3200
Provider Information
Provider Name
Provider Address
Provider City, State, ZIP Code
Provider Communications
Numbers
Provider Change Reason
O
O
O
O
O
1
1
2
1
2
Situational
Required
Situational
Required
Situational
O
1
Coordination of Benefits
Additional Coordination of
Benefits Identifiers
Coordination of Benefits
Eligibility Dates
O
O
1
4
Situational
Situational
O
2
Situational
Coordination of Benefits
Related Entity
Coordination of Benefits
Related Entity Address
Coordination of Benefits Other
Insurance Company City,
State, ZIP Code
Administrative
Communications Contact
O
1
Situational
O
1
Situational
O
1
Required
O
1
Situational
Flexible Spending Account
Monetary Amount Information
Date or Time or Period
Reference Information
O
O
O
O
1
10
10
>1
Additional Reporting
Categories
O
1
Member Reporting Categories
O
1
Situational
5
3
5
N2/5500L
N2/5500
Situational
Situational
Situational
Situational
1
Situational
>1
Situational
1
Reporting Category
Reporting Category Reference
Reporting Category Date
Additional Reporting
Categories Loop Termination
Transaction Set Trailer
M
M
O
O
1
16
1
1
Situational
Situational
Situational
Situational
M
1
Required
Req
M
Max Use
1
Not Defined:
Pos
Id
GE
Segment Name
Functional Group Trailer
2
Repeat
Notes
Usage
Required
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IEA
Interchange Control Trailer
M
1
Required
Notes:
1/0700L
1/0700
1/0700L
1/0700
1/0700L
1/0700
2/0100L
At least one iteration of loop 1000 is required to identify the sender or receiver.
At least one iteration of loop 1000 is required to identify the sender or receiver.
At least one iteration of loop 1000 is required to identify the sender or receiver.
At least one iteration of loop 1000 is required to identify the sender or receiver.
At least one iteration of loop 1000 is required to identify the sender or receiver.
At least one iteration of loop 1000 is required to identify the sender or receiver.
A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a
person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits.
Subscriber information must come before dependent information. The INS segment is used to note if information
being submitted is subscriber information or dependent information.
2/0100 A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a
person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits.
Subscriber information must come before dependent information. The INS segment is used to note if information
being submitted is subscriber information or dependent information.
2/0200 The REF segment is required to link the dependent(s) to the subscriber.
2/0200 The REF segment is required to link the dependent(s) to the subscriber.
2/0200 The REF segment is required to link the dependent(s) to the subscriber.
2/3100L Loop 2310 contains information about the primary care providers for the subscriber or the dependent, and about the
beneficiaries of any employer-sponsored life insurance for the subscriber.
2/3100 Loop 2310 contains information about the primary care providers for the subscriber or the dependent, and about the
beneficiaries of any employer-sponsored life insurance for the subscriber.
2/3200 Either NM1 or N1 will be included depending on whether an individual or organization is being specified.
2/5500L Loop 2500 may only appear for the Subscriber.
2/5500 Loop 2500 may only appear for the Subscriber.
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Interchange Control Header
ISA
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 16
User Option (Usage): Required
Purpose: To start and identify an interchange of zero or more functional groups and interchange-related control segments
Element Summary:
Ref
ISA01
Id
I01
Element Name
Authorization Information Qualifier
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Description: Code identifying the type of information in the Authorization Information
CodeList Summary (Total Codes: 7, Included: 2)
Code
Name
00
No Authorization Information Present (No Meaningful Information in I02)
03
Additional Data Identification
ISA02
I02
M
Authorization Information
AN
10/10
Required
Description: Information used for additional identification or authorization of the interchange sender
or the data in the interchange; the type of information is set by the Authorization Information Qualifier
(I01)
ISA03
I03
M
Security Information Qualifier
ID
2/2
Required
Description: Code identifying the type of information in the Security Information
All valid standard codes are used. (Total Codes: 2)
ISA04
I04
M
Security Information
AN
10/10
Required
Description: This is used for identifying the security information about the interchange sender or the
data in the interchange; the type of information is set by the Security Information Qualifier (I03)
ISA05
I05
M
Interchange ID Qualifier
ID
2/2
Required
Description: Code indicating the system/method of code structure used to designate the sender or
receiver ID element being qualified
CodeList Summary (Total Codes: 41, Included: 9)
Code
Name
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
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
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
ISA06
I06
M
Interchange Sender ID
AN
15/15
Required
Description: Identification code published by the sender for other parties to use as the receiver ID to
route data to them; the sender always codes this value in the sender ID element
ISA07
I05
M
Interchange ID Qualifier
ID
2/2
Required
Description: Code indicating the system/method of code structure used to designate the sender or
receiver ID element being qualified
CodeList Summary (Total Codes: 41, Included: 9)
Code
Name
4
5/11/2011
Benefit Enrollment and Maintenance - 834
01
14
20
27
28
29
30
33
ZZ
ISA08
I07
Duns (Dun & Bradstreet)
Duns Plus Suffix
Health Industry Number (HIN)
Carrier Identification Number as assigned by Health Care Financing Administration
(HCFA)
Fiscal Intermediary Identification Number as assigned by Health Care Financing
Administration (HCFA)
Medicare Provider and Supplier Identification Number as assigned by Health Care
Financing Administration (HCFA)
U.S. Federal Tax Identification Number
National Association of Insurance Commissioners Company Code (NAIC)
Mutually Defined
M
Interchange Receiver ID
AN
15/15
Required
Description: Identification code published by the receiver of the data; When sending, it is used by the
sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route
data to them
ISA09
I08
Interchange Date
M
DT
6/6
Required
M
TM
4/4
Required
1/1
Required
Description: Date of the interchange
ISA10
I09
Interchange Time
Description: Time of the interchange
ISA11
I65
M
Repetition Separator
Description: Type is not applicable; the repetition separator is a delimiter and not a data element; this
field provides the delimiter used to separate repeated occurrences of a simple data element or a
composite data structure; this value must be different than the data element separator, component
element separator, and the segment terminator
ISA12
I11
Interchange Control Version Number
M
ID
5/5
Required
Description: Code specifying the version number of the interchange control segments
CodeList Summary (Total Codes: 20, Included: 1)
Code
Name
00501
Standards Approved for Publication by ASC X12 Procedures Review Board through
October 2003
ISA13
I12
M
Interchange Control Number
N0
9/9
Required
1/1
Required
Description: A control number assigned by the interchange sender
ISA14
I13
M
Acknowledgment Requested
ID
Description: Code indicating sender's request for an interchange acknowledgment
All valid standard codes are used. (Total Codes: 2)
ISA15
I14
M
Interchange Usage Indicator
ID
1/1
Required
Description: Code indicating whether data enclosed by this interchange envelope is test, production
or information
CodeList Summary (Total Codes: 3, Included: 2)
Code
Name
P
Production Data
T
Test Data
ISA16
I15
M
Component Element Separator
1/1
Required
Description: Type is not applicable; the component element separator is a delimiter and not a data
element; this field provides the delimiter used to separate component data elements within a composite
data structure; this value must be different than the data element separator and the segment terminator
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Benefit Enrollment and Maintenance - 834
BCI Requirements:
ISA01 IS REQUIRED AND SHOULD CONTAIN "00"
ISA02 IS REQUIRED AND SHOULD CONTAIN "0000000000"
ISA03 IS REQUIRED AND SHOULD CONTAIN "00"
ISA04 IS REQUIRED AND SHOULD CONTAIN "<BLANK>"
ISA05 IS REQUIRED AND SHOULD CONTAIN "30"
ISA06 IS REQUIRED AND SHOULD CONTAIN "<THE FED TAX ID OF THE
SENDER>"
ISA07 IS REQUIRED AND SHOULD CONTAIN "30"
ISA08 IS REQUIRED AND SHOULD CONTAIN "820344294"
ISA09 IS REQUIRED AND SHOULD CONTAIN "<YYMMDD>"
ISA10 IS REQUIRED AND SHOULD CONTAIN <HHMM>
ISA11 IS REQUIRED AND SHOULD CONTAIN "^"
ISA12 IS REQUIRED AND SHOULD CONTAIN "00501"
ISA13 IS REQUIRED AND SHOULD CONTAIN "<Unique Number>"
ISA14 IS REQUIRED AND SHOULD CONTAIN "0"
ISA15 IS REQUIRED AND SHOULD CONTAIN "<P or T >"
ISA16 IS REQUIRED AND SHOULD CONTAIN ">"
ELEMENT SEPARATOR *
TERMINATOR DELIMITER ~
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Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 8
Functional Group Header
GS
User Option (Usage): Required
Purpose: To indicate the beginning of a functional group and to provide control information
Element Summary:
Ref
GS01
Id
479
Element Name
Functional Identifier Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Description: Code identifying a group of application related transaction sets
CodeList Summary (Total Codes: 262, Included: 1)
Code
Name
BE
Benefit Enrollment and Maintenance (834)
GS02
142
M
Application Sender's Code
AN
2/15
Required
Description: Code identifying party sending transmission; codes agreed to by trading partners
GS03
124
M
Application Receiver's Code
AN
2/15
Required
Description: Code identifying party receiving transmission; codes agreed to by trading partners
GS04
373
M
Date
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
GS05
337
M
Time
TM
4/8
Required
Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds
(00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and
DD = hundredths (00-99)
GS06
28
M
Group Control Number
N0
1/9
Required
1/2
Required
Description: Assigned number originated and maintained by the sender
GS07
455
M
Responsible Agency Code
ID
Description: Code identifying the issuer of the standard; this code is used in conjunction with Data
Element 480
CodeList Summary (Total Codes: 2, Included: 1)
Code
Name
X
Accredited Standards Committee X12
GS08
480
Version / Release / Industry Identifier Code
M
AN
1/12
Required
Description: Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in
DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the
version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by
user); if code in DE455 in GS segment is T, then other formats are allowed
CodeList Summary (Total Codes: 65, Included: 1)
Code
Name
005010X220 Standards Approved for Publication by ASC X12 Procedures Review Board through
October 2003
Semantics:
1. GS04 is the group date.
2. GS05 is the group time.
3. The data interchange control number GS06 in this header must be identical to the same data element in the associated
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Benefit Enrollment and Maintenance - 834
functional group trailer, GE02.
Comments:
1. A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar
transaction sets enclosed by a functional group header and a functional group trailer.
BCI Requirements:
GS01 IS REQUIRED AND SHOULD CONTAIN "BE"
GS02 IS REQUIRED AND SHOULD CONTAIN "<THE FED TAX ID OF THE SENDER
> "NOTE: Fed Tax Id of the Sender - Can also be another Code to identify the Sender
GS03 IS REQUIRED AND SHOULD CONTAIN "820344294"NOTE: Fed Tax ID of the Receiver Can also be another Code to identify the Receiver
GS04 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
GS05 IS REQUIRED AND SHOULD CONTAIN "<HHMMSSDD>"
GS06 IS REQUIRED AND SHOULD CONTAIN "<Unique Number>"
GS07 IS REQUIRED AND SHOULD CONTAIN "X"
GS08 IS REQUIRED AND SHOULD CONTAIN "005010X220A1"
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Pos: 0100
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 3
Transaction Set Header
ST
User Option (Usage): Required
Purpose: To indicate the start of a transaction set and to assign a control number
Element Summary:
Ref
ST01
Id
143
Element Name
Transaction Set Identifier Code
Req
M
Type
ID
Min/Max
3/3
Usage
Required
AN
4/9
Required
Description: Code uniquely identifying a Transaction Set
CodeList Summary (Total Codes: 318, Included: 1)
Code
Name
834
Benefit Enrollment and Maintenance
ST02
329
M
Transaction Set Control Number
Description: Identifying control number that must be unique within the transaction set functional
group assigned by the originator for a transaction set
ST03
1705
Implementation Convention Reference
O
AN
1/35
Required
Description: Reference assigned to identify Implementation Convention
Semantics:
1. The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate
transaction set definition (e.g., 810 selects the Invoice Transaction Set).
2. The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the
appropriate implementation convention to match the transaction set definition. When used, this implementation convention
reference takes precedence over the implementation reference specified in the GS08.
BCI Requirements:
ST01 IS REQUIRED AND SHOULD CONTAIN "834"
ST02 IS REQUIRED AND SHOULD CONTAIN "<Unique Number>"
ST03 IS REQUIRED AND SHOULD CONTAIN "005010X220A1"
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Pos: 0200
Max: 1
Heading - Mandatory
Loop: N/A
Elements: 7
BGN Beginning Segment
User Option (Usage): Required
Purpose: To indicate the beginning of a transaction set
Element Summary:
Ref
BGN01
Id
353
Element Name
Transaction Set Purpose Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
AN
1/50
Required
Description: Code identifying purpose of transaction set
CodeList Summary (Total Codes: 66, Included: 3)
Code
Name
00
Original
15
Re-Submission
22
Information Copy
BGN02
127
M
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
BGN03
373
M
Date
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
BGN04
337
X
Time
TM
4/8
Required
Description: Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds
(00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and
DD = hundredths (00-99)
BGN05
623
O
Time Code
ID
2/2
Situational
Description: Code identifying the time. In accordance with International Standards Organization
standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal
Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in
the codes that follow
All valid standard codes are used. (Total Codes: 51)
BGN06
127
O
Reference Identification
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
BGN08
306
O
Action Code
Description: Code indicating type of action
CodeList Summary (Total Codes: 320, Included: 3)
Code
Name
2
Change (Update)
4
Verify
RX
Replace
Syntax Rules:
1. C0504 - If BGN05 is present, then BGN04 is required.
Semantics:
1. BGN02 is the transaction set reference number.
2. BGN03 is the transaction set date.
10
ID
1/2
Required
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Benefit Enrollment and Maintenance - 834
3. BGN04 is the transaction set time.
4. BGN05 is the transaction set time qualifier.
5. BGN06 is the transaction set reference number of a previously sent transaction affected by the current transaction.
BCI Requirements:
BGN01 IS REQUIRED AND SHOULD CONTAIN "00"
BGN02 IS REQUIRED AND SHOULD CONTAIN "1"
BGN03 IS REQUIRED AND SHOULD CONTAIN "<YYMMDD>"
BGN04 IS REQUIRED AND SHOULD CONTAIN "<HHMM>"
BGN05 IS SITUATIONAL AND SHOULD CONTAIN "MT"
BGN06 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>" NOTE: Will not use
since BGN01 will always be 00 (Original File)
BGN07 IS NOT USED
BGN08 IS REQUIRED AND SHOULD CONTAIN EITHER "2" or "4"
BGN09 IS NOT USED
11
5/11/2011
Benefit Enrollment and Maintenance - 834
Max: 1
Transaction Set Policy Number Pos: 0300
Heading - Optional
REF
Loop: N/A
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code
Name
38
Master Policy Number
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
REF01 IS REQUIRED AND SHOULD CONTAIN "38"
REF02 IS REQUIRED AND SHOULD CONTAIN "<Master Policy Number>"
REF03 IS NOT USED
REF04 IS NOT USED
12
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0400
Max: >1
Heading - Optional
Loop: N/A
Elements: 3
File Effective Date
DTP
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1280, Included: 6)
Code
Name
007
Effective
090
Report Start
091
Report End
303
Maintenance Effective
382
Enrollment
388
Payment Commencement
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
D8
Date Expressed in Format CCYYMMDD
DTP03
1251
M
Date Time Period
AN
1/35
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
BCI Requirements:
DTP01 IS REQUIRED AND SHOULD CONTAIN "007"
DTP02 IS REQUIRED AND SHOULD CONTAIN "D8"
DTP03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
13
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Repeat: 1
Mandatory
Loop: 1000A Elements: N/A
Loop Sponsor Name
User Option (Usage): Required
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0700
Id
N1
Segment Name
Sponsor Name
Req
M
14
Max Use
1
Repeat
Usage
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Max: 1
Heading - Mandatory
Loop: 1000A
Elements: 4
Sponsor Name
N1
User Option (Usage): Required
Purpose: To identify a party by type of organization, name, and code
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 1)
Code
Name
P5
Plan Sponsor
N102
93
Name
X
AN
1/60
Situational
X
ID
1/2
Required
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 3)
Code
Name
24
Employer's Identification Number
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
N104
67
X
Identification Code
AN
2/80
Required
Description: Codze identifying a party or other code
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this
efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
BCI Requirements:
N101 IS REQUIRED AND SHOULD CONTAIN "P5"
N102 IS SITUATIONAL AND SHOULD CONTAINNOTE: Sender the Client Name for
which the Transmission is being created.
N103 IS REQUIRED AND SHOULD CONTAIN "FI"
N104 IS REQUIRED AND SHOULD CONTAIN " <FEDERAL TAX ID OF THE PLAN>"
N105 IS NOT USED
N106 IS NOT USED
15
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Repeat: 1
Mandatory
Loop: 1000B Elements: N/A
Loop Payer
User Option (Usage): Required
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0700
Id
N1
Segment Name
Payer
Req
M
16
Max Use
1
Repeat
Usage
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Max: 1
Heading - Mandatory
Loop: 1000B
Elements: 4
Payer
N1
User Option (Usage): Required
Purpose: To identify a party by type of organization, name, and code
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 1)
Code
Name
IN
Insurer
N102
93
Name
X
AN
1/60
Situational
X
ID
1/2
Required
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 3)
Code
Name
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
Centers for Medicare and Medicaid Services PlanID
N104
67
X
Identification Code
AN
2/80
Required
Description: Code identifying a party or other code
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services PlanID
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this
efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
BCI Requirements:
N101 IS REQUIRED AND SHOULD CONTAIN "IN"
N102 IS SITUATIONAL AND SHOULD CONTAIN "<Blue Cross of Idaho>"
N103 IS REQUIRED AND SHOULD CONTAIN "FI"
N104 IS REQUIRED AND SHOULD CONTAIN "820344294"
N105 IS NOT USED
N106 IS NOT USED
17
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Repeat: 2
Optional
Loop: 1000C Elements: N/A
Loop TPA/Broker Name
User Option (Usage): Situational
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
0700
1200
Id
N1
Segment Name
TPA/Broker Name
Loop 1100C
Req
O
O
18
Max Use
1
Repeat
1
Usage
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0700
Max: 1
Heading - Optional
Loop: 1000C
Elements: 4
TPA/Broker Name
N1
User Option (Usage): Situational
Purpose: To identify a party by type of organization, name, and code
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 2)
Code
Name
BO
Broker or Sales Office
TV
Third Party Administrator (TPA)
N102
93
Name
X
AN
1/60
Required
X
ID
1/2
Required
Description: Free-form name
N103
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 3)
Code
Name
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
Centers for Medicare and Medicaid Services PlanID
N104
67
X
Identification Code
AN
2/80
Required
Description: Code identifying a party or other code
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services PlanID
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this
efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
19
5/11/2011
Benefit Enrollment and Maintenance - 834
Loop TPA/Broker Account Information Pos: 1200 Optional Repeat: 1
Loop: 1100C
Elements: N/A
User Option (Usage): Situational
Purpose: To specify account information
Loop Summary:
Pos
1200
Id
ACT
Segment Name
TPA/Broker Account Information
Req
O
20
Max Use
1
Repeat
Usage
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
TPA/Broker Account
Information
ACT
Pos: 1200
Max: 1
Heading - Optional
Loop: 1100C
Elements: 2
User Option (Usage): Situational
Purpose: To specify account information
Element Summary:
Ref
ACT01
Id
508
Element Name
Account Number
Req
M
Type
AN
Min/Max
1/35
Usage
Required
X
AN
1/35
Situational
Description: Account number assigned
ACT06
508
Account Number
Description: Account number assigned
Syntax Rules:
1. P0304 - If either ACT03 or ACT04 is present, then the other is required.
2. C0506 - If ACT05 is present, then ACT06 is required.
3. C0705 - If ACT07 is present, then ACT05 is required.
Semantics:
1. ACT02 is the name of the account in ACT01.
2. ACT07 is the name associated with the account identified in ACT06.
Comments:
1. ACT06 is an account associated with the account in ACT01.
2. ACT08 indicates if the data for the account in ACT01 is used for billing or information purposes.
21
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0100
Repeat: >1
Optional
Loop: 2000
Elements: N/A
Loop Member Level Detail
User Option (Usage): Required
Purpose: To provide benefit information on insured entities
Loop Summary:
Pos
0100
0200
0200
0200
0250
0300
2600
5500
6880
Id
INS
REF
REF
REF
DTP
Segment Name
Member Level Detail
Subscriber Identifier
Member Policy Number
Member Supplemental Identifier
Member Level Dates
Loop 2100A
Loop 2300
Loop 2500
Loop LS
Req
O
M
O
O
O
O
O
O
O
22
Max Use
1
1
1
13
24
Repeat
1
99
5
1
Usage
Required
Required
Situational
Situational
Situational
Required
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0100
Max: 1
Detail - Optional
Loop: 2000
Elements: 14
Member Level Detail
INS
User Option (Usage): Required
Purpose: To provide benefit information on insured entities
Element Summary:
Ref
INS01
Id
1073
Element Name
Yes/No Condition or Response Code
Req
M
Type
ID
Min/Max
1/1
Usage
Required
2/2
Required
Description: Code indicating a Yes or No condition or response
CodeList Summary (Total Codes: 4, Included: 2)
Code
Name
N
No
Y
Yes
INS02
1069
M
Individual Relationship Code
ID
Description: Code indicating the relationship between two individuals or entities
CodeList Summary (Total Codes: 154, Included: 29)
Code
Name
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
INS03
875
O
Maintenance Type Code
ID
Description: Code identifying the specific type of item maintenance
CodeList Summary (Total Codes: 123, Included: 5)
23
3/3
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Code
001
021
024
025
030
INS04
1203
Name
Change
Addition
Cancellation or Termination
Reinstatement
Audit or Compare
O
Maintenance Reason Code
ID
2/3
Situational
Description: Code identifying the reason for the maintenance change
CodeList Summary (Total Codes: 118, Included: 48)
Code
Name
01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
20
Active
21
Disability
22
Plan Change
25
Change in Identifying Data Elements
26
Declined Coverage
27
Pre-Enrollment
28
Initial Enrollment
29
Benefit Selection
31
Legal Separation
32
Marriage
33
Personnel Data
37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location
59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
24
5/11/2011
Benefit Enrollment and Maintenance - 834
AJ
AL
EC
XN
XT
INS05
1216
Appointment Times not Met in a Timely Manner
Algorithm Assigned Benefit Selection
Member Benefit Selection
Notification Only
Transfer
O
Benefit Status Code
ID
1/1
Required
Description: The type of coverage under which benefits are paid
CodeList Summary (Total Codes: 6, Included: 4)
Code
Name
A
Active
C
Consolidated Omnibus Budget Reconciliation Act (COBRA)
S
Surviving Insured
T
Tax Equity and Fiscal Responsibility Act (TEFRA)
INS06
C052
O
Medicare Status Code
Comp
Situational
Description: To provide Medicare coverage and associated reason for Medicare eligibility
INS06-01
1218
M
Medicare Plan Code
ID
1/1
Required
ID
1/1
Situational
ID
1/2
Situational
Description: Code identifying the Medicare Plan
All valid standard codes are used. (Total Codes: 5)
INS06-02
1701
O
Eligibility Reason Code
Description: Code specifying reason for eligibility
All valid standard codes are used. (Total Codes: 3)
INS07
1219
Consolidated Omnibus Budget
Reconciliation Act (COBRA) Qualifying
Event Code
O
Description: A Qualifying Event is any of the following which results in loss of coverage for a
Qualified Beneficiary
Code
Name
1
Termination of Employment
2
Reductiong of work hours
3
Medicare
4
Death
5
Divorce
6
Separation
7
Ineligible Child
8
Bankruptcy of Retiree’s Former Employer (26 U.S.C.4980B(f)(3)(F))
9
Layoff
10 Leave of Absence
11 Mutually Defined
INS08
584
O
Employment Status Code
ID
2/2
Description: Code showing the general employment status of an employee/claimant
CodeList Summary (Total Codes: 91, Included: 8)
Code
Name
AC
Active
AO
Active Military - Overseas
AU
Active Military - USA
FT
Full-time
L1
Leave of Absence
PT
Part-time
RT
Retired
TE
Terminated
25
Situational
5/11/2011
INS09
Benefit Enrollment and Maintenance - 834
1220
O
Student Status Code
ID
1/1
Situational
Description: Code indicating the student status of the patient if 19 years of age or older, not
handicapped and not the insured
All valid standard codes are used. (Total Codes: 3)
INS10
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
2/3
Situational
Description: Code indicating a Yes or No condition or response
CodeList Summary (Total Codes: 4, Included: 2)
Code
Name
N
No
Y
Yes
INS11
1250
Date Time Period Format Qualifier
X
ID
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
D8
Date Expressed in Format CCYYMMDD
INS12
1251
X
Date Time Period
AN
1/35
Situational
Description: Expression of a date, a time, or range of dates, times or dates and times
INS13
1165
O
Confidentiality Code
ID
1/1
Situational
1/9
Situational
Description: Code indicating the access to insured information
CodeList Summary (Total Codes: 3, Included: 2)
Code
Name
R
Restricted Access
U
Unrestricted Access
INS17
1470
O
Number
N0
Description: A generic number
Syntax Rules:
1. P1112 - If either INS11 or INS12 is present, then the other is required.
Semantics:
1. INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured
is a dependent.
2. INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value indicates an
individual is not handicapped.
3. INS12 is the date of death.
4. INS14, INS15, and INS16 identify where the employee works.
5. INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence
for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
BCI Requirements:
INS01 IS REQUIRED AND SHOULD CONTAIN "<Y or N> "NOTE: Y = Subscriber
(Employee) or N = Non-Subscriber (Dependent) Only one member record and one dependent
record (for each specific dependent) allowed on one file
INS02 IS REQUIRED AND SHOULD CONTAIN "<01 or 18 or 19>"NOTE: 01 = Spouse,
18 = Self, 19 = Child, and all other Codes defined in Implementation Guide
INS03 IS REQUIRED AND SHOULD CONTAIN "<001, 021, 030 or any other applicable
code>"NOTE: Send 001 = Change (Changes File) or 030=Audit or Compare (Full File) If a
26
5/11/2011
Benefit Enrollment and Maintenance - 834
full file is going to be sent, 030 should always be used.
INS04 IS SITUATIONAL AND SHOULD CONTAIN "XN"
INS05 IS REQUIRED AND SHOULD CONTAIN "<A, C, S or T>"NOTE: Active, COBRA,
Surviving Insured, Tax Equity and Fiscal Responsibility Act (TEFRA). Please note, that
when sending in Cobra coverage for a dependent, please send the record in as a dependent
record.
INS06 IS SITUATIONAL AND SHOULD CONTAIN "<Blank> or D or E>"NOTE: Send D
or E; D = Medicare - Part Unknown, E = No Medicare
INS06-1 IS REQUIRED WHEN INS06 IS USED.
INS07 IS SITUATIONAL AND SHOULD CONTAIN "<<Blank> or 1"NOTE: If Benefit
Status (INS05) is C, then will populate 1 (Terminated).
INS08 IS SITUATIONAL AND SHOULD CONTAIN "<FT or PT or RT>"
INS09 IS SITUATIONAL AND SHOULD CONTAIN "<F, N OR P>"
INS10 IS SUTUATIONAL AND SHOULD CONTAIN "<Y or N>"
INS11 IS SITUATIONAL AND SHOULD CONTAIN "D8"
INS12 IS SITUATIONAL AND SHOULD CONTAIN "<CCYYMMDD>"
INS13 IS NOT USED
INS14 IS NOT USED
INS15 IS NOT USED
INS16 NOT USED
INS17 IS SITUATIONAL AND SHOULD CONATAIN " <Number>"NOTE: Birth
Sequence Number, For Dependents Only
27
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0200
Max: 1
Detail - Mandatory
Loop: 2000
Elements: 2
Subscriber Identifier
REF
User Option (Usage): Required
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code
Name
0F
Subscriber Number
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
BCI Requirements:
REF01 IS REQUIRED AND SHOULD CONTAIN "0F"
REF02 IS REQUIRED AND SHOULD CONTAIN "<SSN>"
REF03 IS NOT USED
REF04 IS NOT USED
28
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0200
Max: 1
Detail - Optional
Loop: 2000
Elements: 2
Member Policy Number
REF
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code
Name
1L
Group or Policy Number
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
BCI Requirements:
REF01 IS REQUIRED AND SHOULD CONTAIN "1L"
REF02 IS REQUIRED AND SHOULD CONTAIN "<12345678>"NOTE: Group Number BCI will supply for each Client
REF03 IS NOT USED
REF04 IS NOT USED
29
5/11/2011
Benefit Enrollment and Maintenance - 834
Member Supplemental
Identifier
REF
Pos: 0200
Max: 13
Detail - Optional
Loop: 2000
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 13)
Code
Name
17
Client Reporting Category
23
Client Number
3H
Case Number
4A
Personal Identification Number (PIN)
6O
Cross Reference Number
D3
National Council for Prescription Drug Programs Pharmacy Number
DX
Department/Agency Number
F6
Health Insurance Claim (HIC) Number
P5
Position Code
Q4
Prior Identifier Number
QQ
Unit Number
ZZ
Mutually Defined
ABB
Personal ID Number
REF02
127
X
Reference Identification
AN
1/50
Required
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
ExternalCodeList
Name: 307
Description: National Council for Prescription Drug Programs Pharmacy Number
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
BCI Requirements:
REF01 IS REQUIRED AND SHOULD CONTAIN "23"
REF02 IS REQUIRED AND SHOULD CONTAIN "<Employee ID>"
REF01 IS SITUATIONAL AND SHOULD CONTAIN "DX"
REF02 IS SITUATIONAL AND SHOULD CONTAIN "0001"NOTE:If multiple values, BCI
will provide additional values.
REF01 IS REQUIRED AND SHOULD CONTAIN "<ZZ or 17>"
REF02 IS REQUIRED AND SHOULD CONTAIN "<Class Code or Benefit Level>"NOTE:
Class Code or Benefit Level in which the individual resides BCI will provide for each Client
REF03 IS NOT USED
30
5/11/2011
Benefit Enrollment and Maintenance - 834
REF04 IS NOT USED
31
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0250
Max: 24
Detail - Optional
Loop: 2000
Elements: 3
Member Level Dates
DTP
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1280, Included: 24)
Code
Name
050
Received
286
Retirement
296
Initial Disability Period Return To Work
297
Initial Disability Period Last Day Worked
300
Enrollment Signature Date
301
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
303
Maintenance Effective
336
Employment Begin
337
Employment End
338
Medicare Begin
339
Medicare End
340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
350
Education Begin
351
Education End
356
Eligibility Begin
357
Eligibility End
383
Adjusted Hire
385
Credited Service Begin
386
Credited Service End
393
Plan Participation Suspension
394
Rehire
473
Medicaid Begin
474
Medicaid End
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
D8
Date Expressed in Format CCYYMMDD
DTP03
1251
M
Date Time Period
AN
1/35
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
BCI Requirements:
DTP01 IS REQUIRED AND SHOULD CONTAIN "<336 &337>"
32
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
DPT02 IS REQUIRED AND SHOULD CONTAIN "D8"
DPT03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
DPT01 IS REQUIRED AND SHOULD CONTAIN "<356 & 357>"
DPT02 IS REQUIRED AND SHOULD CONTAIN "D8"
DPT03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
33
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0300
Repeat: 1
Optional
Loop: 2100A Elements: N/A
Loop Member Name
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
0300
0400
0500
0600
0800
1000
Id
NM1
PER
N3
N4
DMG
EC
Segment Name
Member Name
Member Communications Numbers
Member Residence Street Address
Member City, State, ZIP Code
Member Demographics
Employment Class
Req
O
O
O
O
O
O
34
Max Use
1
1
1
1
1
>1
Repeat
Usage
Required
Situational
Situational
Required
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0300
Max: 1
Detail - Optional
Loop: 2100A
Elements: 9
NM1 Member Name
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 2)
Code
Name
74
Corrected Insured
IL
Insured or Subscriber
NM102
1065
Entity Type Qualifier
M
ID
1/1
Required
X
AN
1/60
Required
O
AN
1/35
Situational
O
AN
1/25
Situational
O
AN
1/10
Situational
O
AN
1/10
Situational
X
ID
1/2
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code
Name
1
Person
NM103
1035
Name Last or Organization Name
Description: Individual last name or organizational name
NM104
1036
Name First
Description: Individual first name
NM105
1037
Name Middle
Description: Individual middle name or initial
NM106
1038
Name Prefix
Description: Prefix to individual name
NM107
1039
Name Suffix
Description: Suffix to individual name
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 2)
Code
Name
34
Social Security Number
ZZ
Mutually Defined
NM109
67
X
Identification Code
Description: Code identifying a party or other code
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
35
AN
2/80
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
BCI Requirements:
NM101 IS REQUIRED AND SHOULD CONTAIN "IL"
NM102 IS REQUIRED AND SHOULD CONTAIN "1"
NM103 IS REQUIRED AND SHOULD CONTAIN " <Last Name>"
NM104 IS REQUIRED AND SHOULD CONTAIN "<First Name>"
NM105 IS SITUATIONAL AND SHOULD CONTAIN "<Middle Initial>"
NM106 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM107 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM108 IS SITUATIONAL AND SHOULD CONTAIN "34"
NM109 IS SITUATIONAL AND SHOULD CONTAIN "<SSN>"
NM110 IS NOT USED
NM111 IS NOT USED
NM112 IS NOT USED
36
5/11/2011
Benefit Enrollment and Maintenance - 834
Member Communications
Numbers
PER
Pos: 0400
Max: 1
Detail - Optional
Loop: 2100A
Elements: 7
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Description: Code identifying the major duty or responsibility of the person or group named
CodeList Summary (Total Codes: 238, Included: 1)
Code
Name
IP
Insured Party
PER03
365
Communication Number Qualifier
X
ID
2/2
Required
1/256
Required
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
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
PER04
364
X
Communication Number
AN
Description: Complete communications number including country or area code when applicable
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
1/256
Situational
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
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
PER06
364
X
Communication Number
AN
Description: Complete communications number including country or area code when applicable
PER07
365
Communication Number Qualifier
X
ID
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
37
2/2
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
AP
BN
CP
EM
EX
FX
HP
TE
WP
PER08
364
Alternate Telephone
Beeper Number
Cellular Phone
Electronic Mail
Telephone Extension
Facsimile
Home Phone Number
Telephone
Work Phone Number
X
Communication Number
AN
1/256
Situational
Description: Complete communications number including country or area code when applicable
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
BCI Requirements:
PER01 IS REQUIRED AND SHOULD CONTAIN "IP"
PER02 IS NOT USED
PER03 IS REQUIRED AND SHOULD CONTAIN "<TE or HP>"
PER04 IS REQUIRED AND SHOULD CONTAIN "<Area Code><Phone>"
PER05 IS SITUATIONAL AND SHOULD CONTAIN "EM"
PER06 IS SITUATIONAL AND SHOULD CONTAIN "<Email Address>"
PER07 IS SITUATIONAL AND SHOULD CONTAIN "<BLANK>"
PER08 IS SITUATIONAL AND SHOULD CONTAIN "<BLANK>"
PER09 IS NOT USED
38
5/11/2011
Benefit Enrollment and Maintenance - 834
Member Residence Street
Address
N3
Pos: 0500
Max: 1
Detail - Optional
Loop: 2100A
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
O
AN
1/55
Situational
Description: Address information
N302
166
Address Information
Description: Address information
BCI Requirements:
N301 IS REQUIRED AND SHOULD CONTAIN "<Address Line 1>"
N302 IS SITUATIONAL AND SHOULD CONTAIN "<Address Line 2>"
39
5/11/2011
Benefit Enrollment and Maintenance - 834
Member City, State, ZIP Code
N4
Pos: 0600
Max: 1
Detail - Optional
Loop: 2100A
Elements: 7
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government agency
ExternalCodeList
Name: 22
Description: States and Provinces
N403
116
O
Postal Code
ID
3/15
Situational
Description: Code defining international postal zone code excluding punctuation and blanks (zip code
for United States)
ExternalCodeList
Name: 932
Description: Universal Postal Codes
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
X
ID
1/2
Situational
AN
1/30
Situational
ID
1/3
Situational
Description: Code identifying the country
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N405
309
Location Qualifier
Description: Code identifying type of location
CodeList Summary (Total Codes: 184, Included: 2)
Code
Name
60
Area
CY
County/Parish
N406
310
O
Location Identifier
Description: Code which identifies a specific location
N407
1715
X
Country Subdivision Code
Description: Code identifying the country subdivision
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
40
5/11/2011
Benefit Enrollment and Maintenance - 834
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
BCI Requirements:
N401 IS REQUIRED AND SHOULD CONTAIN "<City Name>"
N402 IS REQUIRED AND SHOULD CONTAIN "<State>"
N403 IS REQUIRED AND SHOULD CONTAIN "<Postal Code>"
N404 IS SITUATIONAL AND SHOULD CONTAIN "<Country Code>"
N405 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
N406 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
41
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 0800
Max: 1
Detail - Optional
Loop: 2100A
Elements: 8
DMG Member Demographics
User Option (Usage): Situational
Purpose: To supply demographic information
Element Summary:
Ref
DMG01
Id
1250
Element Name
Date Time Period Format Qualifier
Req
X
Type
ID
Min/Max
2/3
Usage
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
D8
Date Expressed in Format CCYYMMDD
DMG02
1251
X
Date Time Period
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
DMG03
1068
O
Gender Code
ID
1/1
Required
ID
1/1
Situational
Description: Code indicating the sex of the individual
CodeList Summary (Total Codes: 7, Included: 3)
Code
Name
F
Female
M
Male
U
Unknown
DMG04
1067
O
Marital Status Code
Description: Code defining the marital status of a person
CodeList Summary (Total Codes: 12, Included: 9)
Code
Name
B
Registered Domestic Partner
D
Divorced
I
Single
M
Married
R
Unreported
S
Separated
U
Unmarried (Single or Divorced or Widowed)
W
Widowed
X
Legally Separated
DMG05
C056
Composite Race or Ethnicity Information
X
Comp
Situational
Description: To send general and detailed information on race or ethnicity
DMG05-01
1109
O
Race or Ethnicity Code
ID
1/1
Situational
Description: Code indicating the racial or ethnic background of a person; it is normally self-reported;
Under certain circumstances this information is collected for United States Government statistical
purposes
CodeList Summary (Total Codes: 23, Included: 16)
Code
Name
7
Not Provided
8
Not Applicable
A
Asian or Pacific Islander
B
Black
C
Caucasian
42
5/11/2011
Benefit Enrollment and Maintenance - 834
D
E
F
G
H
I
J
N
O
P
Z
DMG05-02
1270
Subcontinent Asian American
Other Race or Ethnicity
Asian Pacific American
Native American
Hispanic
American Indian or Alaskan Native
Native Hawaiian
Black (Non-Hispanic)
White (Non-Hispanic)
Pacific Islander
Mutually Defined
X
Code List Qualifier Code
ID
1/3
Situational
AN
1/30
Situational
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code
Name
RET
Classification of Race or Ethnicity
DMG05-03
1271
X
Industry Code
Description: Code indicating a code from a specific industry code list
ExternalCodeList
Name: 859
Description: Classification of Race or Ethnicity
DMG06
1066
Citizenship Status Code
O
ID
1/2
Situational
X
ID
1/3
Situational
AN
1/30
Situational
Description: Code indicating citizenship status
CodeList Summary (Total Codes: 18, Included: 7)
Code
Name
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
DMG10
1270
Code List Qualifier Code
Description: Code identifying a specific industry code list
CodeList Summary (Total Codes: 948, Included: 1)
Code
Name
REC
Race or Ethnicity Collection Code
DMG11
1271
X
Industry Code
Description: Code indicating a code from a specific industry code list
ExternalCodeList
Name: 860
Description: Race or Ethnicity Collection Code
Syntax Rules:
1. P0102 - If either DMG01 or DMG02 is present, then the other is required.
2. P1011 - If either DMG10 or DMG11 is present, then the other is required.
3. C1105 - If DMG11 is present, then DMG05 is required.
Semantics:
43
5/11/2011
Benefit Enrollment and Maintenance - 834
1. DMG02 is the date of birth.
2. DMG07 is the country of citizenship.
3. DMG09 is the age in years.
4. DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
BCI Requirements:
DMG01 IS REQUIRED AND SHOULD CONTAIN "D8"
DMG02 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
DMG03 IS REQUIRED AND SHOULD CONTAIN "<F, M >"
DMG04 IS SITUATIONAL AND SHOULD CONTAIN "<M, I>"
DMG05 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
DMG06 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
DMG07 IS NOT USED
DMG08 IS NOT USED
DMG09 IS NOT USED
DMG10 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
44
5/11/2011
EC
Benefit Enrollment and Maintenance - 834
Pos: 1000
Max: >1
Detail - Optional
Loop: 2100A
Elements: 3
Employment Class
User Option (Usage): Situational
Purpose: To provide class of employment information
Element Summary:
Ref
EC01
Id
1176
Element Name
Employment Class Code
Req
O
Type
ID
Min/Max
2/3
Usage
Required
ID
2/3
Situational
Description: Code indicating category of employee
CodeList Summary (Total Codes: 70, Included: 19)
Code
Name
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
EC02
1176
O
Employment Class Code
Description: Code indicating category of employee
CodeList Summary (Total Codes: 70, Included: 19)
Code
Name
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
45
5/11/2011
Benefit Enrollment and Maintenance - 834
22
23
EC03
1176
President
Vice President
O
Employment Class Code
Description: Code indicating category of employee
CodeList Summary (Total Codes: 70, Included: 19)
Code
Name
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
Semantics:
1. EC04 is percent of ownership.
2. EC05 applies to the entire segment.
46
ID
2/3
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 2600
Repeat: 99
Optional
Loop: 2300
Elements: N/A
Loop Health Coverage
User Option (Usage): Situational
Purpose: To provide information on health coverage
Loop Summary:
Pos
2600
2700
2800
2900
2900
3100
4000
Id
HD
DTP
AMT
REF
REF
Segment Name
Health Coverage
Health Coverage Dates
Health Coverage Policy
Health Coverage Policy Number
Prior Coverage Months
Loop 2310
Loop 2320
Req
O
O
O
O
O
O
O
47
Max Use
1
6
9
14
1
Repeat
30
5
Usage
Situational
Required
Situational
Situational
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 2600
Max: 1
Detail - Optional
Loop: 2300
Elements: 5
Health Coverage
HD
User Option (Usage): Situational
Purpose: To provide information on health coverage
Element Summary:
Ref
HD01
Id
875
Element Name
Maintenance Type Code
Req
M
Type
ID
Min/Max
3/3
Usage
Required
2/3
Required
1/50
Situational
Description: Code identifying the specific type of item maintenance
CodeList Summary (Total Codes: 123, Included: 8)
Code
Name
001
Change
002
Delete
021
Addition
024
Cancellation or Termination
025
Reinstatement
026
Correction
030
Audit or Compare
032
Employee Information Not Applicable
HD03
1205
O
Insurance Line Code
ID
Description: Code identifying a group of insurance products
CodeList Summary (Total Codes: 55, Included: 22)
Code
Name
AG
Preventative Care/Wellness
AH
24 Hour Care
AJ
Medicare Risk
AK
Mental Health
HE
Hearing
MM
Major Medical
UR
Utilization Review
DCP
Dental Capitation
DEN
Dental
EPO
Exclusive Provider Organization
FAC
Facility
HLT
Health
HMO
Health Maintenance Organization
LTC
Long-Term Care
LTD
Long-Term Disability
MOD
Mail Order Drug
PDG
Prescription Drug
POS
Point of Service
PPO
Preferred Provider Organization
PRA
Practitioners
STD
Short-Term Disability
VIS
Vision
HD04
1204
O
Plan Coverage Description
AN
Description: A description or number that identifies the plan or coverage
HD05
1207
O
Coverage Level Code
ID
3/3
Description: Code indicating the level of coverage being provided for this insured
48
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
CodeList Summary (Total Codes: 25, Included: 18)
Code
Name
CHD
Children Only
DEP
Dependents Only
E1D
Employee and One Dependent
E2D
Employee and Two Dependents
E3D
Employee and Three Dependents
E5D
Employee and One or More Dependents
E6D
Employee and Two or More Dependents
E7D
Employee and Three or More Dependents
E8D
Employee and Four or More Dependents
E9D
Employee and Five or More Dependents
ECH
Employee and Children
EMP
Employee Only
ESP
Employee and Spouse
FAM
Family
IND
Individual
SPC
Spouse and Children
SPO
Spouse Only
TWO
Two Party
HD09
1073
Yes/No Condition or Response Code
O
ID
1/1
Situational
Description: Code indicating a Yes or No condition or response
All valid standard codes are used. (Total Codes: 4)
Semantics:
1. HD06 is the number of collateral dependents for the primary insured. A collateral dependent is a relative related by blood
or marriage who resides in the home and is dependent on the employee for support.
2. HD07 is the number of sponsored dependents for the primary insured. A sponsored dependent is a dependent between the
ages of 19 and 25 who is not in school.
3. HD09 is a late enrollee indicator. A "Y" value indicates the insured is a late enrollee, which can result in a reduction of
benefits; an "N" value indicates the insured is a regular enrollee.
4. HD11 is a prescription drug service coverage indicator. A "Y" value indicates that prescription drug service coverage
applies; an "N" value indicates that prescription drug service coverage does not apply.
BCI Requirements:
HD01 IS REQUIRED AND SHOULD CONTAIN "<001, 021, 024, 030>"
HD02 IS NOT USED
HD03 IS REQUIRED AND SHOULD CONTAIN "<MM, DEN, HMO, VIS, EPO, HMO,
PDG, POS, PPO, DCP>"
HD04 IS SITUATIONAL AND SHOULD CONTAIN "<PLAN CODE>"
HD05 IS REQUIRED AND SHOULD CONTAIN "<All Possible Codes>"
HD06 IS NOT USED
HD07 IS NOT USED
HD08 IS NOT USED
HD09 IS SITUATIONAL BUT NOT REQUIRED BY THIS GUIDE
HD10 IS NOT USED
HD11 IS NOT USED
49
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 2700
Max: 6
Detail - Optional
Loop: 2300
Elements: 3
Health Coverage Dates
DTP
User Option (Usage): Required
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1280, Included: 7)
Code
Name
300
Enrollment Signature Date
303
Maintenance Effective
343
Premium Paid to Date End
348
Benefit Begin
349
Benefit End
543
Last Premium Paid Date
695
Previous Period
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 2)
Code
Name
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP03
1251
M
Date Time Period
AN
1/35
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
BCI Requirements:
DTP01 IS REQUIRED AND SHOULD CONTAIN "<348 & 349 & 303>"
DTP02 IS REQUIRED AND SHOULD CONTAIN "D8"
DTP03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
50
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 2800
Max: 9
Detail - Optional
Loop: 2300
Elements: 2
AMT Health Coverage Policy
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Req
M
Type
ID
Min/Max
1/3
Usage
Required
R
1/18
Required
Description: Code to qualify amount
CodeList Summary (Total Codes: 1765, Included: 7)
Code
Name
R
Spend Down
B9
Co-insurance - Actual
C1
Co-Payment Amount
D2
Deductible Amount
FK
Other Unlisted Amount
P3
Premium Amount
EBA
Expected Expenditure Amount
AMT02
782
M
Monetary Amount
Description: Monetary amount
51
5/11/2011
Benefit Enrollment and Maintenance - 834
Health Coverage Policy
Number
REF
Pos: 2900
Max: 14
Detail - Optional
Loop: 2300
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 14)
Code
Name
17
Client Reporting Category
1L
Group or Policy Number
9V
Payment Category
CE
Class of Contract Code
E8
Service Contract (Coverage) Number
M7
Medical Assistance Category
RB
Rate code number
X9
Internal Control Number
XM
Issuer Number
ZX
County Code
ZZ
Mutually Defined
PID
Program Identification Number
XX1
Special Program Code
XX2
Service Area Code
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
BCI Requirements:
SEGMENT IS OPTIONAL BUT IF USED, SHOULD CONTAIN THE FOLLOWING:
REF01 SHOULD CONTAIN "1L"
REF02 SHOULD CONTAIN "<12345678>" NOTE: Group or Policy Number if available.
REF03 IS NOT USED
REF04 IS NOT USED
52
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 2900
Max: 1
Detail - Optional
Loop: 2300
Elements: 2
Prior Coverage Months
REF
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 1)
Code
Name
QQ
Unit Number
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
53
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 3100
Repeat: 30
Optional
Loop: 2310
Elements: N/A
Loop Provider Information
User Option (Usage): Situational
Purpose: To reference a line number in a transaction set
Loop Summary:
Pos
3100
3200
3500
3600
3700
3950
Id
LX
NM1
N3
N4
PER
PLA
Segment Name
Provider Information
Provider Name
Provider Address
Provider City, State, ZIP Code
Provider Communications Numbers
Provider Change Reason
Req
O
O
O
O
O
O
54
Max Use
1
1
2
1
2
1
Repeat
Usage
Situational
Required
Situational
Required
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 3100
Max: 1
Detail - Optional
Loop: 2310
Elements: 1
Provider Information
LX
User Option (Usage): Situational
Purpose: To reference a line number in a transaction set
Element Summary:
Ref
LX01
Id
554
Element Name
Assigned Number
Req
M
Type
N0
Min/Max
1/6
Description: Number assigned for differentiation within a transaction set
BCI Requirements:
LX01 SHOULD CONTAIN "1"
55
Usage
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 3200
Max: 1
Detail - Optional
Loop: 2310
Elements: 10
NM1 Provider Name
User Option (Usage): Required
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 9)
Code
Name
1X
Laboratory
3D
Obstetrics and Gynecology Facility
80
Hospital
FA
Facility
OD
Doctor of Optometry
P3
Primary Care Provider
QA
Pharmacy
QN
Dentist
Y2
Managed Care Organization
NM102
1065
Entity Type Qualifier
M
ID
1/1
Required
X
AN
1/60
Situational
O
AN
1/35
Situational
O
AN
1/25
Situational
O
AN
1/10
Situational
O
AN
1/10
Situational
X
ID
1/2
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 2)
Code
Name
1
Person
2
Non-Person Entity
NM103
1035
Name Last or Organization Name
Description: Individual last name or organizational name
NM104
1036
Name First
Description: Individual first name
NM105
1037
Name Middle
Description: Individual middle name or initial
NM106
1038
Name Prefix
Description: Prefix to individual name
NM107
1039
Name Suffix
Description: Suffix to individual name
NM108
66
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 4)
Code
Name
34
Social Security Number
FI
Federal Taxpayer's Identification Number
SV
Service Provider Number
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM109
67
X
Identification Code
56
AN
2/80
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Description: Code identifying a party or other code
ExternalCodeList
Name: 537
Description: Centers for Medicare and Medicaid Services National Provider Identifier
NM110
706
X
Entity Relationship Code
ID
2/2
Description: Code describing entity relationship
CodeList Summary (Total Codes: 124, Included: 3)
Code
Name
25
Established Patient
26
Not Established Patient
72
Unknown
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
BCI Requirements:
NM101 IS REQUIRED AND SHOULD CONTAIN " <P3, QN>"
NM102 IS REQUIRED AND SHOULD C0NTAIN "<1 or 2>"
NM103 IS SITUATIONAL AND SHOULD CONTAIN "<PCP Name>"
NM104 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM105 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM106 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM107 IS SITUATIONAL AND SHOULD CONTAIN "<Blank>"
NM108 IS SITUATIONAL AND SHOULD CONTAIN "SV"
NM109 IS SITUATIONAL AND SHOULD CONTAIN "<PCP Code>"
NM110 IS SITUATIONAL AND SHOULD CONTAIN "<25, 26, 72>"
NM111 IS NOT USED
NM112 IS NOT USED
57
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 3500
Max: 2
Detail - Optional
Loop: 2310
Elements: 2
Provider Address
N3
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
O
AN
1/55
Situational
Description: Address information
N302
166
Address Information
Description: Address information
58
5/11/2011
Benefit Enrollment and Maintenance - 834
Provider City, State, ZIP Code
N4
Pos: 3600
Max: 1
Detail - Optional
Loop: 2310
Elements: 5
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government agency
ExternalCodeList
Name: 22
Description: States and Provinces
N403
116
O
Postal Code
ID
3/15
Situational
Description: Code defining international postal zone code excluding punctuation and blanks (zip code
for United States)
ExternalCodeList
Name: 932
Description: Universal Postal Codes
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
X
ID
1/3
Situational
Description: Code identifying the country
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
Description: Code identifying the country subdivision
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
59
5/11/2011
Benefit Enrollment and Maintenance - 834
Provider Communications
Numbers
PER
Pos: 3700
Max: 2
Detail - Optional
Loop: 2310
Elements: 7
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Description: Code identifying the major duty or responsibility of the person or group named
CodeList Summary (Total Codes: 238, Included: 1)
Code
Name
IC
Information Contact
PER03
365
Communication Number Qualifier
X
ID
2/2
Required
1/256
Required
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
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
PER04
364
X
Communication Number
AN
Description: Complete communications number including country or area code when applicable
PER05
365
Communication Number Qualifier
X
ID
2/2
Situational
1/256
Situational
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
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
PER06
364
X
Communication Number
AN
Description: Complete communications number including country or area code when applicable
PER07
365
Communication Number Qualifier
X
ID
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 9)
Code
Name
60
2/2
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
AP
BN
CP
EM
EX
FX
HP
TE
WP
PER08
364
Alternate Telephone
Beeper Number
Cellular Phone
Electronic Mail
Telephone Extension
Facsimile
Home Phone Number
Telephone
Work Phone Number
X
Communication Number
AN
1/256
Situational
Description: Complete communications number including country or area code when applicable
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
61
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 3950
Max: 1
Detail - Optional
Loop: 2310
Elements: 4
Provider Change Reason
PLA
User Option (Usage): Situational
Purpose: To indicate action to be taken for the location specified and to qualify the location specified
Element Summary:
Ref
PLA01
Id
306
Element Name
Action Code
Req
M
Type
ID
Min/Max
1/2
Usage
Required
ID
2/3
Required
Description: Code indicating type of action
CodeList Summary (Total Codes: 320, Included: 1)
Code
Name
2
Change (Update)
PLA02
98
M
Entity Identifier Code
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 1)
Code
Name
1P
Provider
PLA03
373
M
Date
DT
8/8
Required
Description: Date expressed as CCYYMMDD where CC represents the first two digits of the
calendar year
PLA05
1203
O
Maintenance Reason Code
ID
2/3
Description: Code identifying the reason for the maintenance change
CodeList Summary (Total Codes: 118, Included: 13)
Code
Name
14
Voluntary Withdrawal
22
Plan Change
46
Current Customer Information File in Error
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
Semantics:
1. PLA03 is the effective date for the action identified in PLA01.
2. When used, PLA04 is the effective time for the action identified in PLA01.
62
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 4000
Repeat: 5
Optional
Loop: 2320
Elements: N/A
Loop Coordination of Benefits
User Option (Usage): Situational
Purpose: To supply information on coordination of benefits
Loop Summary:
Pos
4000
4050
4070
4100
Id
COB
REF
DTP
Segment Name
Coordination of Benefits
Additional Coordination of Benefits Identifiers
Coordination of Benefits Eligibility Dates
Loop 2330
63
Req
O
O
O
O
Max Use
1
4
2
Repeat
3
Usage
Situational
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 4000
Max: 1
Detail - Optional
Loop: 2320
Elements: 4
COB Coordination of Benefits
User Option (Usage): Situational
Purpose: To supply information on coordination of benefits
Element Summary:
Ref
COB01
Id
1138
Element Name
Payer Responsibility Sequence Number Code
Req
O
Type
ID
Min/Max
1/1
Usage
Required
Description: Code identifying the insurance carrier's level of responsibility for a payment of a claim
CodeList Summary (Total Codes: 14, Included: 4)
Code
Name
P
Primary
S
Secondary
T
Tertiary
U
Unknown
COB02
127
O
Reference Identification
AN
1/50
Situational
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
COB03
1143
O
Coordination of Benefits Code
ID
1/1
Required
Description: Code identifying whether there is a coordination of benefits
CodeList Summary (Total Codes: 9, Included: 3)
Code
Name
1
Coordination of Benefits
5
Unknown
6
No Coordination of Benefits
COB04
1365
O
Service Type Code
Description: Code identifying the classification of service
CodeList Summary (Total Codes: 190, Included: 11)
Code
Name
1
Medical Care
35
Dental Care
48
Hospital - Inpatient
50
Hospital - Outpatient
54
Long Term Care
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
A4
Psychiatric
AG
Skilled Nursing Care
AL
Vision (Optometry)
BB
Partial Hospitalization (Psychiatric)
Semantics:
1. COB02 is the policy number.
64
ID
1/2
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Additional Coordination of
Benefits Identifiers
REF
Pos: 4050
Max: 4
Detail - Optional
Loop: 2320
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 4)
Code
Name
60
Account Suffix Code
6P
Group Number
SY
Social Security Number
ZZ
Mutually Defined
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
65
5/11/2011
Benefit Enrollment and Maintenance - 834
Coordination of Benefits
Eligibility Dates
DTP
Pos: 4070
Max: 2
Detail - Optional
Loop: 2320
Elements: 3
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1280, Included: 2)
Code
Name
344
Coordination of Benefits Begin
345
Coordination of Benefits End
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
D8
Date Expressed in Format CCYYMMDD
DTP03
1251
M
Date Time Period
AN
1/35
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
66
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Loop Coordination of Benefits Related
Entity
Pos: 4100
Repeat: 3
Optional
Loop: 2330
Elements: N/A
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Loop Summary:
Pos
4100
4300
4400
Id
NM1
N3
N4
4500
PER
Segment Name
Coordination of Benefits Related Entity
Coordination of Benefits Related Entity Address
Coordination of Benefits Other Insurance
Company City, State, ZIP Code
Administrative Communications Contact
67
Req
O
O
O
Max Use
1
1
1
O
1
Repeat
Usage
Situational
Situational
Required
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
NM1 Coordination of Benefits
Pos: 4100
Max: 1
Detail - Optional
Loop: 2330
Elements: 5
Related Entity
User Option (Usage): Situational
Purpose: To supply the full name of an individual or organizational entity
Element Summary:
Ref
NM101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 3)
Code
Name
36
Employer
GW
Group
IN
Insurer
NM102
1065
Entity Type Qualifier
M
ID
1/1
Required
X
AN
1/60
Situational
ID
1/2
Situational
Description: Code qualifying the type of entity
CodeList Summary (Total Codes: 16, Included: 1)
Code
Name
2
Non-Person Entity
NM103
1035
Name Last or Organization Name
Description: Individual last name or organizational name
NM108
66
X
Identification Code Qualifier
Description: Code designating the system/method of code structure used for Identification Code (67)
CodeList Summary (Total Codes: 241, Included: 3)
Code
Name
FI
Federal Taxpayer's Identification Number
NI
National Association of Insurance Commissioners (NAIC) Identification
XV
Centers for Medicare and Medicaid Services PlanID
NM109
67
X
Identification Code
AN
Description: Code identifying a party or other code
ExternalCodeList
Name: 540
Description: Centers for Medicare and Medicaid Services PlanID
Syntax Rules:
1. P0809 - If either NM108 or NM109 is present, then the other is required.
2. C1110 - If NM111 is present, then NM110 is required.
3. C1203 - If NM112 is present, then NM103 is required.
Semantics:
1. NM102 qualifies NM103.
Comments:
1. NM110 and NM111 further define the type of entity in NM101.
2. NM112 can identify a second surname.
68
2/80
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Coordination of Benefits
Related Entity Address
N3
Pos: 4300
Max: 1
Detail - Optional
Loop: 2330
Elements: 2
User Option (Usage): Situational
Purpose: To specify the location of the named party
Element Summary:
Ref
N301
Id
166
Element Name
Address Information
Req
M
Type
AN
Min/Max
1/55
Usage
Required
O
AN
1/55
Situational
Description: Address information
N302
166
Address Information
Description: Address information
69
5/11/2011
Benefit Enrollment and Maintenance - 834
Coordination of Benefits Other
Insurance Company City,
State, ZIP Code
N4
Pos: 4400
Max: 1
Detail - Optional
Loop: 2330
Elements: 5
User Option (Usage): Required
Purpose: To specify the geographic place of the named party
Element Summary:
Ref
N401
Id
19
Element Name
City Name
Req
O
Type
AN
Min/Max
2/30
Usage
Required
X
ID
2/2
Situational
Description: Free-form text for city name
N402
156
State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government agency
ExternalCodeList
Name: 22
Description: States and Provinces
N403
116
O
Postal Code
ID
3/15
Situational
Description: Code defining international postal zone code excluding punctuation and blanks (zip code
for United States)
ExternalCodeList
Name: 932
Description: Universal Postal Codes
ExternalCodeList
Name: 51
Description: ZIP Code
N404
26
Country Code
X
ID
2/3
Situational
X
ID
1/3
Situational
Description: Code identifying the country
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
N407
1715
Country Subdivision Code
Description: Code identifying the country subdivision
ExternalCodeList
Name: 5
Description: Countries, Currencies and Funds
Syntax Rules:
1. E0207 - Only one of N402 or N407 may be present.
2. C0605 - If N406 is present, then N405 is required.
3. C0704 - If N407 is present, then N404 is required.
Comments:
1. A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
2. N402 is required only if city name (N401) is in the U.S. or Canada.
70
5/11/2011
Benefit Enrollment and Maintenance - 834
Administrative
Communications Contact
PER
Pos: 4500
Max: 1
Detail - Optional
Loop: 2330
Elements: 3
User Option (Usage): Situational
Purpose: To identify a person or office to whom administrative communications should be directed
Element Summary:
Ref
PER01
Id
366
Element Name
Contact Function Code
Req
M
Type
ID
Min/Max
2/2
Usage
Required
Description: Code identifying the major duty or responsibility of the person or group named
CodeList Summary (Total Codes: 238, Included: 1)
Code
Name
CN
General Contact
PER03
365
Communication Number Qualifier
X
ID
2/2
Required
1/256
Required
Description: Code identifying the type of communication number
CodeList Summary (Total Codes: 42, Included: 1)
Code
Name
TE
Telephone
PER04
364
X
Communication Number
AN
Description: Complete communications number including country or area code when applicable
Syntax Rules:
1. P0304 - If either PER03 or PER04 is present, then the other is required.
2. P0506 - If either PER05 or PER06 is present, then the other is required.
3. P0708 - If either PER07 or PER08 is present, then the other is required.
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Pos: 5500
Repeat: 5
Optional
Loop: 2500
Elements: N/A
Loop Flexible Spending Account
User Option (Usage): Situational
Purpose: To supply flexible spending account information
Loop Summary:
Pos
5500
5600
5700
5750
Id
FSA
AMT
DTP
REF
Segment Name
Flexible Spending Account
Monetary Amount Information
Date or Time or Period
Reference Information
Req
O
O
O
O
72
Max Use
1
10
10
>1
Repeat
Usage
Situational
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 5500
Max: 1
Detail - Optional
Loop: 2500
Elements: 9
Flexible Spending Account
FSA
User Option (Usage): Situational
Purpose: To supply flexible spending account information
Element Summary:
Ref
FSA01
Id
875
Element Name
Maintenance Type Code
Req
M
Type
ID
Min/Max
3/3
Usage
Required
1/1
Situational
Description: Code identifying the specific type of item maintenance
All valid standard codes are used. (Total Codes: 123)
FSA02
1202
Flexible Spending Account Selection Code
O
ID
Description: Code indicating selection of a type of Flexible Spending Account
All valid standard codes are used. (Total Codes: 5)
FSA03
1203
O
Maintenance Reason Code
ID
2/3
Situational
Description: Code identifying the reason for the maintenance change
All valid standard codes are used. (Total Codes: 118)
FSA04
508
Account Number
O
AN
1/35
Situational
O
ID
1/1
Situational
Description: Account number assigned
FSA05
594
Frequency Code
Description: Code indicating frequency or type of activities or actions being reported
All valid standard codes are used. (Total Codes: 23)
FSA06
1204
O
Plan Coverage Description
AN
1/50
Situational
Description: A description or number that identifies the plan or coverage
FSA07
1161
O
Product Option Code
ID
1/2
Situational
1/2
Situational
1/2
Situational
Description: Code indicating an option chosen for the product
All valid standard codes are used. (Total Codes: 30)
FSA08
1161
O
Product Option Code
ID
Description: Code indicating an option chosen for the product
All valid standard codes are used. (Total Codes: 30)
FSA09
1161
O
Product Option Code
ID
Description: Code indicating an option chosen for the product
All valid standard codes are used. (Total Codes: 30)
Semantics:
1. FSA04 is the flexible spending account (FSA) policy number.
2. FSA05 specifies the frequency of contribution.
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Benefit Enrollment and Maintenance - 834
BCI Requirements:
FSA01 IS REQUIRED AND SHOULD CONTAIN "<001, 021, 024, 030>"
FSA02 IS SITUATIONAL AND SHOULD CONTAIN "<D for Dependent Care or H for
Healthcare>"
FSA03 IS SITUATIONAL AND SHOULD CONTAIN "<36 for Contribution or Plan
Allocation>"
FSA04 IS SITUATIONAL
FSA05 IS SITUATIONAL. POSSIBLE VALUES ARE:
1
Weekly
2
Biweekly
3
Semimonthly
4
Monthly
5
Other
6
Daily
7
Annual
8
Two Calendar Months
9
Lump-Sum Separation Allowance
B
Year-to-Date
C
Single
H
Hourly
Q
Quarterly
S
Semiannual
U
Unknown
Z
Mutually Defined
FSA06 IS SITUATIONAL
FSA07 IS SITUATIONAL. POSSIBLE VALUES ARE:
1
2
3
5
6
7
8
9
A
B
C
D
N
O
S
10
11
12
13
14
15
28
Pretax
Post-tax
Qualified4
Non-qualified
401K
Individual Retirement Account
Keogh
Simplified Employee Pension
Single Premium
First to Die
Last to Die
Child Rider
Discontinue One-Bill Submission
Benefit Continuation
One-Bill Submission
Salary Continuation
Flexible Premium
Variable Premium
Fixed Premium
Registered under the Income Tax Act of Canada
Non-Registered under the Income Tax Act of Canada
Registered Spousal Case
Exclusive
74
5/11/2011
29
30
31
BA
GA
NC
PD
Benefit Enrollment and Maintenance - 834
Shopped
Lead Reinsurer
Facultative Excess
Bank Account
Government Allocation
One-Bill Submission Not Chosen
Payroll Deduction
FSA08 IS SITUATIONAL BUT NOT REQUIRED BY THIS GUIDE
FSA09 IS SITUATIONAL BUT NOT REQUIRED BY THIS GUIDE
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AMT Monetary Amount Information
Pos: 5600
Max: 10
Detail - Optional
Loop: 2500
Elements: 3
User Option (Usage): Situational
Purpose: To indicate the total monetary amount
Element Summary:
Ref
AMT01
Id
522
Element Name
Amount Qualifier Code
Req
M
Type
ID
Min/Max
1/3
Usage
Required
M
R
1/18
Required
O
ID
1/1
Situational
Description: Code to qualify amount
All valid standard codes are used. (Total Codes: 1765)
AMT02
782
Monetary Amount
Description: Monetary amount
AMT03
478
Credit/Debit Flag Code
Description: Code indicating whether amount is a credit or debit
All valid standard codes are used. (Total Codes: 2)
BCI Requirements:
AMT01 IS REQUIRED AND SHOULD CONTAIN "<1>"
AMT02 IS REQUIRED AND SHOULD CONTAIN THE DOLLAR AMOUNT OF
CONTRIBUTION.
AMT03 IS SITUATIONAL. POSSIBLE VALUES ARE “<C for Credit or D for Debit>”
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Pos: 5700
Max: 10
Detail - Optional
Loop: 2500
Elements: 3
Date or Time or Period
DTP
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
All valid standard codes are used. (Total Codes: 1280)
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
All valid standard codes are used. (Total Codes: 42)
DTP03
1251
M
Date Time Period
AN
1/35
Required
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
BCI Requirements:
DTP01 IS REQUIRED AND SHOULD CONTAIN "<390 - Payroll Begin &391 - Payroll
End>"
DPT02 IS REQUIRED AND SHOULD CONTAIN "D8"
DPT03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"
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Pos: 5750
Max: >1
Detail - Optional
Loop: 2500
Elements: 4
Reference Information
REF
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Situational
Description: Code qualifying the Reference Identification
All valid standard codes are used. (Total Codes: 1731)
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
REF03
352
X
Description
AN
1/80
Situational
Description: A free-form description to clarify the related data elements and their content
REF04
C040
O
Reference Identifier
Comp
Situational
Description: To identify one or more reference numbers or identification numbers as specified by the
Reference Qualifier
REF04-01
128
M
Reference Identification Qualifier
ID
2/3
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
All valid standard codes are used. (Total Codes: 1731)
REF04-02
127
M
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
REF04-03
128
X
Reference Identification Qualifier
ID
2/3
Situational
AN
1/50
Situational
Description: Code qualifying the Reference Identification
All valid standard codes are used. (Total Codes: 1731)
REF04-04
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
REF04-05
128
X
Reference Identification Qualifier
ID
2/3
Situational
AN
1/50
Situational
Description: Code qualifying the Reference Identification
All valid standard codes are used. (Total Codes: 1731)
REF04-06
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
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Loop Additional Reporting Categories
Pos: 6880
Repeat: 1
Optional
Loop: LS
Elements: N/A
User Option (Usage): Situational
Purpose: To indicate that the next segment begins a loop
Loop Summary:
Pos
6880
6881
6885
Id
LS
LE
Segment Name
Additional Reporting Categories
Loop 2700
Additional Reporting Categories Loop
Termination
Req
O
O
O
79
Max Use
1
Repeat
>1
1
Usage
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Additional Reporting
Categories
LS
Pos: 6880
Max: 1
Detail - Optional
Loop: LS
Elements: 1
User Option (Usage): Situational
Purpose: To indicate that the next segment begins a loop
Element Summary:
Ref
LS01
Id
447
Element Name
Loop Identifier Code
Req
M
Type
AN
Min/Max
1/4
Usage
Required
Description: The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE
Semantics:
1. One loop may be nested contained within another loop, provided the inner nested loop terminates before the outer loop.
When specified by the standard setting body as mandatory, this segment in combination with "LE", must be used. It is not
to be used if not specifically set forth for use. The loop identifier in the loop header and trailer must be identical. The value
for the identifier is the loop ID of the required loop segment. The loop ID number is given on the transaction set diagram in
the appropriate ASC X12 version/release.
Comments:
1. See Figures Appendix for an explanation of the use of the LS and LE segments.
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Loop Member Reporting Categories
Pos: 6881
Repeat: >1
Optional
Loop: 2700
Elements: N/A
User Option (Usage): Situational
Purpose: To reference a line number in a transaction set
Loop Summary:
Pos
6881
6882
Id
LX
Segment Name
Member Reporting Categories
Loop 2750
Req
O
M
81
Max Use
1
Repeat
1
Usage
Situational
Situational
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Member Reporting Categories
LX
Pos: 6881
Max: 1
Detail - Optional
Loop: 2700
Elements: 1
User Option (Usage): Situational
Purpose: To reference a line number in a transaction set
Element Summary:
Ref
LX01
Id
554
Element Name
Assigned Number
Req
M
Type
N0
Min/Max
1/6
Description: Number assigned for differentiation within a transaction set
82
Usage
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 6882
Repeat: 1
Mandatory
Loop: 2750
Elements: N/A
Loop Reporting Category
User Option (Usage): Situational
Purpose: To identify a party by type of organization, name, and code
Loop Summary:
Pos
6882
6883
6884
Id
N1
REF
DTP
Segment Name
Reporting Category
Reporting Category Reference
Reporting Category Date
Req
M
M
O
83
Max Use
1
16
1
Repeat
Usage
Situational
Situational
Situational
5/11/2011
Benefit Enrollment and Maintenance - 834
Pos: 6882
Max: 1
Detail - Mandatory
Loop: 2750
Elements: 2
Reporting Category
N1
User Option (Usage): Situational
Purpose: To identify a party by type of organization, name, and code
Element Summary:
Ref
N101
Id
98
Element Name
Entity Identifier Code
Req
M
Type
ID
Min/Max
2/3
Usage
Required
Description: Code identifying an organizational entity, a physical location, property or an individual
CodeList Summary (Total Codes: 1500, Included: 1)
Code
Name
75
Participant
N102
93
X
Name
AN
1/60
Required
Description: Free-form name
Syntax Rules:
1. R0203 - At least one of N102 or N103 is required.
2. P0304 - If either N103 or N104 is present, then the other is required.
Comments:
1. This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this
efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
2. N105 and N106 further define the type of entity in N101.
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Reporting Category Reference
REF
Pos: 6883
Max: 16
Detail - Mandatory
Loop: 2750
Elements: 2
User Option (Usage): Situational
Purpose: To specify identifying information
Element Summary:
Ref
REF01
Id
128
Element Name
Reference Identification Qualifier
Req
M
Type
ID
Min/Max
2/3
Usage
Required
AN
1/50
Required
Description: Code qualifying the Reference Identification
CodeList Summary (Total Codes: 1731, Included: 16)
Code
Name
00
Contracting District Number
17
Client Reporting Category
18
Plan Number
19
Division Identifier
26
Union Number
3L
Branch Identifier
6M
Application Number
9V
Payment Category
9X
Account Category
GE
Geographic Number
LU
Location Number
YY
Geographic Key
ZZ
Mutually Defined
PID
Program Identification Number
XX1
Special Program Code
XX2
Service Area Code
REF02
127
X
Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the
Reference Identification Qualifier
Syntax Rules:
1. R0203 - At least one of REF02 or REF03 is required.
Semantics:
1. REF04 contains data relating to the value cited in REF02.
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Pos: 6884
Max: 1
Detail - Optional
Loop: 2750
Elements: 3
Reporting Category Date
DTP
User Option (Usage): Situational
Purpose: To specify any or all of a date, a time, or a time period
Element Summary:
Ref
DTP01
Id
374
Element Name
Date/Time Qualifier
Req
M
Type
ID
Min/Max
3/3
Usage
Required
Description: Code specifying type of date or time, or both date and time
CodeList Summary (Total Codes: 1280, Included: 1)
Code
Name
007
Effective
DTP02
1250
Date Time Period Format Qualifier
M
ID
2/3
Required
Description: Code indicating the date format, time format, or date and time format
CodeList Summary (Total Codes: 42, Included: 2)
Code
Name
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP03
1251
M
Date Time Period
AN
1/35
Description: Expression of a date, a time, or range of dates, times or dates and times
Semantics:
1. DTP02 is the date or time or period format that will appear in DTP03.
86
Required
5/11/2011
Benefit Enrollment and Maintenance - 834
Additional Reporting
Categories Loop Termination
LE
Pos: 6885
Max: 1
Detail - Optional
Loop: LS
Elements: 1
User Option (Usage): Situational
Purpose: To indicate that the loop immediately preceding this segment is complete
Element Summary:
Ref
LE01
Id
447
Element Name
Loop Identifier Code
Req
M
Type
AN
Min/Max
1/4
Usage
Required
Description: The loop ID number given on the transaction set diagram is the value for this data
element in segments LS and LE
Semantics:
1. One loop may be nested contained within another loop, provided the inner nested loop terminates before the other loop.
When specified by the standards setting body as mandatory, this segment in combination with "LS", must be used. It is not
to be used if not specifically set forth for use. The loop identifier in the loop header and trailer must be identical. The value
for the identifier is the loop ID of the required loop beginning segment. The loop ID number is given on the transaction set
diagram in the appropriate ASC X12 version/release.
Comments:
1. See Figures Appendix for an explanation of the use of the LE and LS segments.
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Pos: 6900
Max: 1
Detail - Mandatory
Loop: N/A
Elements: 2
Transaction Set Trailer
SE
User Option (Usage): Required
Purpose: To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning
(ST) and ending (SE) segments)
Element Summary:
Ref
SE01
Id
96
Element Name
Number of Included Segments
Req
M
Type
N0
Min/Max
1/10
Usage
Required
Description: Total number of segments included in a transaction set including ST and SE segments
SE02
329
M
Transaction Set Control Number
AN
4/9
Required
Description: Identifying control number that must be unique within the transaction set functional
group assigned by the originator for a transaction set
Comments:
1. SE is the last segment of each transaction set.
BCI Requirements:
SE01 IS REQUIRED AND SHOULD CONTAIN "<Number>"
SE02 IS REQUIRED AND SHOULD CONTAIN "<Number>"
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Benefit Enrollment and Maintenance - 834
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
Functional Group Trailer
GE
User Option (Usage): Required
Purpose: To indicate the end of a functional group and to provide control information
Element Summary:
Ref
GE01
Id
97
Element Name
Number of Transaction Sets Included
Req
M
Type
N0
Min/Max
1/6
Usage
Required
Description: Total number of transaction sets included in the functional group or interchange
(transmission) group terminated by the trailer containing this data element
GE02
28
M
Group Control Number
N0
1/9
Required
Description: Assigned number originated and maintained by the sender
Semantics:
1. The data interchange control number GE02 in this trailer must be identical to the same data element in the associated
functional group header, GS06.
Comments:
1. The use of identical data interchange control numbers in the associated functional group header and trailer is designed to
maximize functional group integrity. The control number is the same as that used in the corresponding header.
BCI Requirements:
GE01 IS REQUIRED AND SHOULD CONTAIN "<Number>"
GE02 IS REQUIRED AND SHOULD CONTAIN "<Number>"
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Interchange Control Trailer
IEA
Pos:
Max: 1
Not Defined - Mandatory
Loop: N/A
Elements: 2
User Option (Usage): Required
Purpose: To define the end of an interchange of zero or more functional groups and interchange-related control segments
Element Summary:
Ref
IEA01
Id
I16
Element Name
Number of Included Functional Groups
Req
M
Type
N0
Min/Max
1/5
Usage
Required
Description: A count of the number of functional groups included in an interchange
IEA02
I12
M
Interchange Control Number
N0
Description: A control number assigned by the interchange sender
BCI Requirements:
IEA01 IS REQUIRED AND SHOULD CONTAIN "<Number>"
IEA02 IS REQUIRED AND SHOULD CONTAIN "<Number>"
90
9/9
Required