834 EDI Segment Name
834 EDI Data Element
834 EDI Data Type
Required
(Y/N)
ISA - Interchange Control Header
Authorization Information Qualifier
VARCHAR2(2)
Y
Authorization Information
VARCHAR2(10)
Y
Security Information Qualifier
VARCHAR2(2)
Y
Security Information
VARCHAR2(10)
Y
Interchange ID Qualifier
VARCHAR2(2)
Y
Interchange Sender ID
VARCHAR2(15)
Y
Interchange ID Qualifier
VARCHAR2(2)
Y
Interchange Receiver ID
VARCHAR2(15)
Y
Interchange Date (YYMMDD)
DATE
Y
Interchange Time (HHMM)
TIME
Y
Repetition Separator
VARCHAR2(1)
Y
Interchange Control Version Number
VARCHAR2(5)
Y
Interchange Control Number
VARCHAR2(9)
Y
Acknowledgment Requested
NUMBER(1)
Y
Interchange Usage Indicator
VARCHAR2(1)
Y
Component Element Separator
VARCHAR2(1)
Y
Functional Identifier Code.
VARCHAR2(2)
Y
Application Sender’s Code
VARCHAR2(15)
Y
Application Receiver’s Code
VARCHAR2(15)
Y
Date (CCYYMMDD)
DATE
Y
Time (HHMM)
TIME
Y
Group Control Number
NUMBER(9)
Y
Responsible Agency Code
VARCHAR2(2)
Y
Version/Release/Industry/Identifier Code
VARCHAR2(12)
Y
Transaction Set Identifier Code
NUMBER(3)
Y
Transaction Set Control Number
VARCHAR2(9)
Y
Implementation Convention Reference
VARCHAR2(35)
Y
Transaction Set Purpose Code
VARCHAR2(2)
Y
Reference Identification
VARCHAR2(50)
Y
Date
date
Y
Time
Time
Y
Action Code
VARCHAR2(2)
Y
Reference Identification Qualifier
NUMBER(3)
Y
GS-Functional Group Header
Header
100 ST - Transaction Set Header
200 BGN - Beginning Segment
300 REF - Transaction Set Policy Number
Reference Identification
VARCHAR2(50)
Y
Date/Time Qualifier
NUMBER(3)
Date Time Period Format Qualifier
VARCHAR2(3)
Y
Date Time Period
VARCHAR2(35)
Y
Entity Identifier Code
VARCHAR2(3)
Y
Name
VARCHAR2(60)
N
Identification Code Qualifier
VARCHAR2(2)
Y
Identification Code
VARCHAR2(80)
Y
Entity Identifier Code
VARCHAR2(3)
Y
Name
VARCHAR2(60)
N
Identification Code Qualifier
VARCHAR2(2)
Y
Identification Code
VARCHAR2(80)
Y
Yes/No Condition or Response Code
VARCHAR2(1)
Y
Individual Relationship Code
VARCHAR2(2)
Y
Maintenance Type Code
VARCHAR2(3)
Y
Maintenance Reason Code
VARCHAR2(3)
N
Benefit Status Code
VARCHAR2(1)
Y
400 DTP - File Effective Date
1000A Sponsor
700 N1 - Sponsor Name
1000B Payer
700 N1 - Payer
2000 Member Level Detail
100 INS - Member Level Detail
Date Time Period Format Qualifier
VARCHAR2(3)
N
Date Time Period
VARCHAR2(35)
N
Reference Identification Qualifier
VARCHAR2(3)
Y
Reference Identification
VARCHAR2(50)
Y
Reference Identification Qualifier
VARCHAR2(3)
Y
Reference Identification
VARCHAR2(50)
Y
Date/Time Qualifier
NUMBER(3)
Y
Date Time Period Format Qualifier
VARCHAR2(3)
Y
Date Time Period
VARCHAR2(35)
Y
Entity Identifier Code
VARCHAR2(3)
Y
Entity Type Qualifier
NUMBER(1)
Y
Name Last or Organization Name
VARCHAR2(60)
Y
Name First
VARCHAR2(35)
N
Name Middle
VARCHAR2(25)
N
Name Prefix
VARCHAR2(10)
N
Name Suffix
VARCHAR2(10)
N
Identification Code Qualifier
VARCHAR2(2)
N
Identification Code
VARCHAR2(80)
N
Contact Function Code
VARCHAR2(2)
Y
Communication Number Qualifier
VARCHAR2(2)
Y
Communication Number
VARCHAR2(256)
Y
Communication Number Qualifier
VARCHAR2(2)
Y
Communication Number
VARCHAR2(256)
Y
Communication Number Qualifier
VARCHAR2(2)
Y
Communication Number
VARCHAR2(256)
Y
200 REF - Subscriber Identifier
200 REF - Member Supplemental Identifier
250 DTP - Member Level Dates
2100A Member Name
300 NM1 - Member Name
400 PER - Member Communications Numbers
500 N3 - Member Residence Street Address
Address Information
VARCHAR2(55)
Y
Address Information
VARCHAR2(55)
N
City Name
VARCHAR2(30)
Y
State or Province Code
VARCHAR2(2)
N
Postal Code
VARCHAR2(15)
N
Country Code
VARCHAR2(3)
N
Location Qualifier
VARCHAR2(2)
N
Location Identifier
VARCHAR2(30)
N
Date Time Period Format Qualifier
VARCHAR2(3)
Y
Date Time Period
VARCHAR2(35)
Y
Gender Code
VARCHAR2(1)
Y
Marital Status Code
VARCHAR2(1)
Y
Race or Ethnicity Code
VARCHAR2(1)
N
Citizenship Status Code
NUMBER(2)
N
Health-Related Code
VARCHAR2(1)
N
600 N4 - Member City, State, ZIP Code
800 DMG - Member Demographics
1300 HLH - Member Health Information
1500 LUI - Member Language
Identification Code Qualifier
VARCHAR2(2)
N
Identification Code
VARCHAR2(80)
N
Description
VARCHAR2(80)
N
Use of Language Indicator
NUMBER(2)
N
Entity Identifier Code
NUMBER(3)
Y
Entity Type Qualifier
NUMBER(1)
Y
Name Last or Organization Name
VARCHAR2(60)
Y
Name First
VARCHAR2(35)
N
Name Middle
VARCHAR2(25)
N
Name Prefix
VARCHAR2(10)
N
Name Suffix
VARCHAR2(10)
N
Identification Code Qualifier
VARCHAR2(2)
N
Identification Code
VARCHAR2(80)
N
Date Time Period Format Qualifier
VARCHAR2(3)
N
Date Time Period
VARCHAR2(35)
N
Gender Code
VARCHAR2(1)
N
Marital Status Code
VARCHAR2(1)
N
Race or Ethnicity Code
VARCHAR2(1)
N
Citizenship Status Code
NUMBER(2)
N
Entity Identifier Code
NUMBER(3)
Y
Entity Type Qualifier
NUMBER(1)
Y
Address Information
VARCHAR2(55)
Y
Address Information
VARCHAR2(55)
N
City Name
VARCHAR2(30)
Y
State or Province Code
VARCHAR2(2)
N
Postal Code
VARCHAR2(15)
N
Country Code
VARCHAR2(3)
N
2100B Incorrect Member Name
300 NM1 - Incorrect Member Name
800 DMG - Incorrect Member Demographics
2100C - Member Mailing Address
300 NM1 - Member Mailing Address
500 N3 - Member Mail Street Address
600 N4 - Member Mail City, State, ZIP Code
2100D - Member Employer (Only applicable for SHOP)
300 NM1 - Member Employer
Entity Identifier Code
NUMBER(3)
Y
Entity Type Qualifier
NUMBER(1)
Y
Name Last or Organization Name
VARCHAR2(60)
N
Name First
VARCHAR2(35)
N
Name Middle
VARCHAR2(25)
N
Name Prefix
VARCHAR2(10)
N
Name Suffix
VARCHAR2(10)
N
Identification Code Qualifier
NUMBER(2)
N
Identification Code
VARCHAR2(80)
N
Contact Function Code
VARCHAR2(2)
Y
Name
VARCHAR2(60)
N
Communication Number Qualifier
VARCHAR2(2)
Y
Communication Number
VARCHAR2(256)
Y
Communication Number Qualifier
VARCHAR2(2)
N
Communication Number
VARCHAR2(256)
N
Address Information
VARCHAR2(55)
Y
Address Information
VARCHAR2(55)
N
City Name
VARCHAR2(30)
Y
State or Province Code
VARCHAR2(2)
N
Postal Code
VARCHAR2(15)
N
Country Code
VARCHAR2(3)
N
Entity Identifier Code
VARCHAR2(3))
Y
Entity Type Qualifier
NUMBER(1)
Y
Name Last or Organization Name
VARCHAR2(60)
Y
Name First
VARCHAR2(35)
N
Name Middle
VARCHAR2(25)
N
Name Prefix
VARCHAR2(10)
N
Name Suffix
VARCHAR2(10)
N
Identification Code Qualifier
VARCHAR2(2)
N
Identification Code
VARCHAR2(80)
N
VARCHAR2(2)
Y
400 PER - Member Employer Communications Numbers
500 N3 - Member Employer Street Address
600 N4 - Member Employer City, State, ZIP Code
2100G - Responsible Person
300 NM1 - Responsible Person
400 PER - Responsible Person Communications Numbers
Contact Function Code
Communication Number Qualifier
VARCHAR2(2)
Y
Communication Number
VARCHAR2(256)
Y
Communication Number Qualifier
VARCHAR2(2)
N
Communication Number
VARCHAR2(256)
N
Address Information
VARCHAR2(55)
Y
Address Information
VARCHAR2(55)
N
City Name
VARCHAR2(30)
Y
State or Province Code
VARCHAR2(2)
N
Postal Code
VARCHAR2(15)
N
Country Code
VARCHAR2(3)
N
Maintenance Type Code
VARCHAR2(3)
Y
Insurance Line Code
VARCHAR2(3)
Y
Plan Coverage Description
VARCHAR2(50)
N
Coverage Level Code
VARCHAR2(3)
N
Yes/No Condition or Response Code
VARCHAR2(1)
N
Date/Time Qualifier
NUMBER(3)
Y
500 N3 - Responsible Person Street Address
600 N4 - Responsible Person City, State, ZIP Code
2300 - Health Coverage
2300 HD - Health Coverage
2700 DTP - Health Coverage Dates
Date/Time Qualifier
NUMBER(3)
Y
Date Time Period Format Qualifier
VARCHAR2(3)
Y
Date Time Period
VARCHAR2(35)
Y
Amount Qualifier Code
VARCHAR2(3)
Y
Monetary Amount
R
Y
Loop Identifier Code
VARCHAR2(4)
Y
Assigned Number
NUMBER (6)
Y
Entity Identifier Code
NUMBER(3)
Y
Name
VARCHAR2(60)
Y
Reference Identification Qualifier
VARCHAR2(3)
Y
Reference Identification
VARCHAR2(50)
Y
2800 AMT - Health Coverage Policy
Additional Reporting Categories
6880 LS - Additional Reporting Categories
2700 - Member Reporting Categories
6881 LX - Member Reporting Categories
2750 - Reporting Category
6882 N1 - Reporting Category
6883 REF - Reporting Category Reference
Reference Identification
VARCHAR2(50)
Y
Date/Time Qualifier
VARCHAR2(3)
Y
Date Time Period Format Qualifier
VARCHAR2(3)
Y
Date Time Period
VARCHAR2(35)
Y
Loop Identifier Code
VARCHAR2(4)
Y
Number of Included Segments
NUMBER(10)
Y
Transaction Set Control Number
VARCHAR2(9)
Y
Number of transaction sets included
NUMBER(6)
Y
Group control number
NUMBER(9)
Y
Number of included functional groups
NUMBER(5)
Y
Interchange control number
NUMBER(9)
Y
6884 DTP - Reporting Category Date
6885 LE - Additional Reporting Categories Loop Termination
Transaction Set Trailer
GE- Functional Group Trailer
IEA-Interchange Control Trailer
Mapping Logic
This field will be populated with 00 – No Authorization information.
This field will be populated with Spaces.
This field will be populated with 00 – No Security information.
This field will be populated with Spaces.
30= U.S. Federal Tax Identification Number
Tax ID number of HBE
30= U.S. Federal Tax Identification Number
Tax ID number of the Issuer
This field will be populated with System Date Format - YYMMDD
This field will be populated with System Time Format = HHMM
Use ^ for repetition separator.
This field will be populated with 00501
This field will be populated with the Interchange Control Number. Note ISA13 =
IEA02
This field will be populated with 0 – no Acknowledgement
This field will be populated with “P‟ in Production Mode and “T‟ in Test Mode.
This field will be populated with Value = ":"
This field will be populated with ‘BE’ – Benefit Enrollment
Tax ID number of HBE
Tax ID number of the Issuer
This field will be populated with System Date Format - YYMMDD
This field will be populated with System Time Format = HHMM
This field will be populated with Group Control Number. Note GS06 = GE02
This field will be populated with ‘X’ for X12.
This field will be populated with ‘005010X220A1’ version number for the 834
transaction.
This Field will be populated with “834”
Calculated sequential number
This field will be same as GS08 i.e. ‘005010X220A1’
“00” – Original. Copy of the original will be available from archive.
This field will be populated with the Sender’s Reference Number. This will be a
unique number generated by the HBE.
The date the file was created
The time of day the file was created
Values to be allowed:
“2” = Change (Update). Used to identify a transaction of additions, terminations and
changes to the current enrollment.
“4” = Verify (Audit)
This field will be populated with “38”
This be the QHP Plan ID.
303 = Maintenance Effective
D8 = Date expressed in format CCYYMMDD
File Effective Date. Format is “CCYYMMDD”.
This will be the primary applicant for an individual application and employer for a
SHOP application.
This field will be populated with “FI” and “24”
This will be the issuer information. Will default to IN
This will be the issuer name
Will be FI
Issuer FEIN
The INS01 indicates the status of the insured. A “Y” value indicates the insured is a
subscriber: an “N” value indicates the insured is a dependent. If the subscriber and
the insured are always the same individual, you can default this to “Y”.
01 – Spouse
19 – Child
18 – Self
G8 – Other Relationship
Code Values used:
• 001 – Change
• 021 – Additions
• 024 – Terminations
• 025 – Reinstatement
• 030 – Audit
a. 01 = Divorce
b. 02 = Birth
c. 03 = Death
d. 05 = Adoption
e. 07 = Termination of Benefits
f. 08 = Termination of Employment
g. 22 = Plan Change
h. 28 = Initial Enrollment
i. 32 = Marriage
j. 59 = Non Payment
k. AI = No Reason Given
Populated with “A” Active or left out for other reason codes.
“D8” Send when required by X12 syntax. This element captures date of death.
Client Date of Death in the CCYYMMDD format.
This field is populated with “0F” Subscriber Number(Person ID).
This will be the unique exchange Person ID (Subscriber ID) created by the HBE.
This field is populated with “ZZ” Person ID for dependents.
This will be the unique exchange Person ID created by the HBE.
050 = Enrollment application received
303 = Maintenance Effective
336 = Employment Begin
337 = Employment End
356 = Eligibility Begin
357 = Eligibility End
This field is populated with “D8”
This field is populated with Status Information Effective Date in CCYYMMDD format.
This field is populated with “IL” (Insured or Subscriber) or “74” (Corrected Insured).
This code identifies if this is a correction to a previous enrollment or if it is a new, or
update, enrollment transaction.
Will be 1
This field is populated with Client’s Last Name.
This field is populated with Client’s First Name.
This field is populated with Client’s Middle Initial.
Send if supplied by subscriber
Send if supplied by subscriber
Client ID Qualifier This field is populated with “34” – Social Security Number.
This field is populated with the Client’s Social Security Number (when available).
Insured Party This field is populated with “IP” for Insured Party.
System will send the primary and alternate phone numbers captured in the HBE and
the email address (if available).
TE = Phone number (As the 1st occurance)
AP = Alternate phone number
EM = email
This field is populated with Client’s primary phone number.
System will send the alternate phone number if available.
AP = Alternate phone number
This field is populated with Client’s alternate phone number.
System will send the email address (if available).
EM = email
This field is populated with the email.
Address Information Line 1. Note: This is the client’s residence address.
Address Information Line 2 – Populated if second address line exists. Note: This is the
client’s residence address.
City Name Note: This is the client’s residence address.
State or Province Code Note: This is the client’s residence address.
Postal Code Medical Residential Zip Code. Note: This is the client’s residence address
This field will be populated if the country code is other than “US”
Populated with “60”
Populated with the Rate Region Code
N/A
Recipient Birth Date Populated with Client’s Date of Birth in the CCYYMMDD format.
“M” – Male
“F” – Female
“U” – Unknown
“D” – Divorced
“M” – Married
“S” – Single
“W” – Widowed
7 – Not Provided
8 – Not Applicable
A – Asian or Pacific Islander
B – Black
C – Caucasian
D – Subcontinent Asian American
E – Other Race or Ethnicity
F – Asian Pacific American
G – Native American
H – Hispanic
I – American Indian or Alaskan Native
J – Native Hawaiian
N – Black (Non-Hispanic)
O – White (Non-Hispanic)
P – Pacific Islander
Z – Mutually Defined
Citizen Status
“1” – US citizen
“3” – Resident Alien
“4” – Illegal Alien
This will have values:N: None
T: Tobacco Use
Populated with “LE”.
Populated with Language Code
N/A
N/A
When the Incorrect Member loop 2100B is used and NM101 = 70, the entity
identifier in loop 2100A must be NM101 = 74.
“1” Person
Prior incorrect insured last name.
Note: This is called “Name Last or Organizational Name” in 834 PDF
Prior incorrect insured first name
Prior incorrect insured middle name
Prior incorrect insured name prefix. Send if supplied by the subscriber
Prior incorrect insured name suffix. Send if supplied by the subscriber
Populated with “34” Prior incorrect insured Social Security Number (when available)
Prior incorrect insured Social Security Number (when available).
This field will be populated with “D8”
This field will be populated with the Prior incorrect insured birth date.
This field will be populated with the Prior incorrect insured gender code.
“F” – Female
“M” – Male
“U” – Unknown
N/A
N/A
N/A
This is the member mailing address if different from the residence address in 2100A
or when a dependent's address is different from the subscriber.
This is “31” for Postal mailing address.
This is “1” for Person.
Address Information Line 1
Address Information Line 2
City Name
State
Postal code
This field will be populated if the country code is other than “US”.
This field will be populated with “36”
This field will be populated with “1”
This field will be the name of the individual assigned as the administrator for the
organization
N/A
N/A
N/A
N/A
This field will be populated with either “24” – Employer Identification Number or
“34” - SSN
N/A
Head of Household This field is populated with “EP”.
Member Employer communication contact
“TE” - Phone Number
This field is populated with the Employer contact’s Phone Number.
“TE” - Phone Number (when available)
This field is populated with the Employer Contact’s Other Phone Number (when
available).
Address Information Line 1.
Address Information Line 2 – populated if second address line exists.
City Name
State or Province Code
Postal Code
Country Code
“QD” for Responsible Party
“E1” for Person or Other Entity Legally Responsible for a child
“S1” Parent
“X4” Spouse
“9K” Tax Filer
“1” Person
Head of Household’s last name.
Note: This is called “Name Last or Organizational Name” in 834 PDF
Head of Household’s first name
Head of Household’s middle name
Head of Household’s name prefix. Send if supplied by the subscriber
Head of Household’s name suffix. Send if supplied by the subscriber
Populated with “34” Head of Household’s Social Security Number (when available)
Head of Household’s Social Security Number (when available).
Head of Household This field is populated with “RP”.
“TE” - Phone Number
This field is populated with the Head of Household’s Phone Number.
“TE” – Phone Number (when available)
This field is populated with the Head of Household’s Other Phone Number (when
available).
Address Information Line 1.
Address Information Line 2 – populated if second address line exists.
City Name
State or Province Code
Postal Code
Country Code
Populated with:
“001” - Change
“021” – Addition
“024” – Cancellation or Termination
“030” – Audit
This field is populated with “MM” or “DEN” (Standalone Dental).
The value in this field will be the plan name.
This will be populated with:
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
Late enrollment indicator
“303” = Transaction Effective Date
“348” = Health Plan coverage Begin Date
“349” = Health Plan coverage End Date.
"357" = Eligibility End
Please refer section 4 “Reporting of Dates in the 834” for the dates reported for each
maintenance type code.
This field is populated with “D8”
CCYYMMDD
Date Plan Coverage Begins/Ends in Update file or first day of the Month (for which
premium info is
being sent) in the Audit file.
“P3” – Premium Amount
Absolute premium amount.
Set to 2700
Squential number for member's additional reporting categories.
This will be 75
The code values will be:APTC AMT
CSR AMT
TOT IND RES AMT
TOT EMP RES AMT
RATING AREA
OTH PAY AMT 1
OTH PAY AMT 2
CSR ELIG CAT
REL TO TAX FILER
SOURCE EXCHG ID
SEP REASON
ADDL MAINT
DENRIDER
PRE AMT TOTAL
This will be 9V - Payment Category for APTC AMT, TOT IND RES AMT, TOT EMP RES
AMT
This will be 9X - Account Category for PRE AMT TOTAL, Rating Area
This will be ZZ for CSR Category and Dental Rider Indicator
This will be:
PRE AMT TOTAL
TOT IND RES AMT
TOT EMP RES AMT
APTC Amount
CSR Eligibility Category
Dental Rider Indicator
“007” – Effective Date
This field is populated with “D8”
CCYYMMDD
Set to 2700
This field will be populated with the number of included segments.
This field will be populated with the Transaction Set Control Number.
Total number of transaction sets included in the functional group
Assigned number originated and maintained by the sender. Needs to match GS06
Number of functional groups included in an interchange
A control number assigned by the interchange sender