MAPPING SPECIFICATIONS - Zendesk · Web viewSeg ID Name Usage Repeat Repeat ST Transaction Set...

Delta Dental

Electronic Data InterchangeTransaction Set Implementation Guide

Health CareBenefit Enrollment and

Maintenance

5010834 Files

Function of 834 Files Delta Dental prefers that full files are sent for eligibility. An 834 full file contains members that are currently eligible on the sponsors system and additions, terminations and changes for members that have incurred one of those activities since the last full file was sent to the Delta Dental.

This guide contains the 834 segments, elements and their values that Delta Dental requires to enroll and maintain member eligibility, as well as some optional segments. All valid HIPAA 5010 segments, elements and values are accepted by Delta Dental whether or not we use them. If HIPAA 5010 segments, elements and values other than what are shown in our guide are necessary to enroll and maintain member eligibility, it will have to be agreed upon by both parties prior to sending files.

Delta DentalElectronic Data Interchange 834 Mapping Version 00501005/10/23

2

834 Benefit Enrollment and Maintenance Loop

Seg ID Name Usage Repeat Repeat ISA Interchange Control Header M 0 NoneGS Functional Group Header M 0 NoneTable 1 - Header

LoopSeg ID Name Usage Repeat Repeat

ST Transaction Set Number M 1 NoneBGN Beginning Segment M 1 None

LOOP ID – 1000A SPONSOR NAME 1N1 Sponsor Name M 1

LOOP ID – 1000B PAYER NAME 1N1 Payer Name M 1

LOOP ID – 1000C TPA/BROKER NAME 1N1 TPA/Broker Name C 1

Table 2 – DetailLoop

Seg ID Name Usage Repeat Repeat LOOP ID – 2000 MEMBER LEVEL DETAIL > 1

INS Member Level Detail M 1REF Member SSN M 1REF Member Group Number C 1REF Member Subgroup ID C 1REF Member CAID C 1REF Member Carrier ID C 1DTP Eligibility End Date C 1DTP Employment Date C 1

LOOP ID – 2100A MEMBER NAME DETAIL 1NM1 Member Name M 1N3 Member Street Address M 1N4 Member City, State, ZIP Code M 1DMG Member Demographic Information M 1

LOOP ID – 2100B INCORRECT MEMBER NAME 1NM1 Member Name C 1

LOOP ID – 2100G RESPONSIBLE PERSON 1NM1 Responsible Person Name O 1

LOOP ID – 2300 HEALTH COVERAGE 1HD Health Coverage M 1DTP Benefit Begin C 1DTP Benefit End C 1REF Benefit Group Number C 1REF Benefit Subgroup ID C 1

SE Transaction Set Trailer M 1


3

GE Functional Group Trailer M 1 NoneIEA Interchange Control Trailer M 1 None


4

ISA – Interchange Control HeaderUsage : MandatorySegment Max UseWithin Loop : 1Loop Repeat : NONELoop ID : NONE

Example:ISA*00*bbbbbbbbbb*00*bbbbbbbbbb*01*xxxxx4321bbbbbb*01*xxxxx0123bbbbbb*120101*1452*U*00501*000000001*0*P*:~

Note b = blank Min/Max

Segment Usage Name Values Description Length

ISA01 M Authorization Information Qualifier “00” No Authorization information present. 2/2

ISA02 M Authorization Information Element should consist of 10 spaces 10/10

ISA03 M Security Info Qualifier “00” No Security info present. 2/2

ISA04 M Security Info Element should consist of 10 spaces 10/10

ISA05 M Sender Interchange ID Qualifier “01” Duns (Dun & Bradstreet) 2/2“ZZ” Mutually Defined

ISA06 M Interchange Sender ID Element must be space filled to the right 15/15To a length of 15

ISA07 M Receiver Interchange ID Qualifier “01” Duns (Dun & Bradstreet) 2/2. Mutually Defined

ISA08 M Interchange receiver ID See Duns in Supplement 15/15

ISA09 M Interchange Date YYMMDD 6/6

ISA10 M Interchange Time HHMM 4/4

ISA11 M Repetition Separator “^” U.S. EDI Community of ASC X12, 1/1TDCC, and UCS

ISA12 M Interchange control Version “00501” 5/5

ISA13 M Interchange control number 9 digit control number must match the 9/9 control number of the IEA02 element

ISA14 M Acknowledgment Requested “0” No Acknowledgment Requested 1/1

ISA15 M Usage Indicator “P” Production 1/1“T” Test

ISA16 M Component element separator “: “ 1/1


5

GS – Functional Group HeaderUsage : MandatorySegment Max UseWithin Loop : 1Loop Repeat : NONELoop ID : NONE

Example:GS*BE*xxxxx4321*xxxxx0123*20120101*1452*000000001*X*005010X220~

Min/MaxSegment Usage Name Values Description Length

GS01 M Functional Identifier Code “BE” Benefit Enrollment and Maintenance 2/2.

GS02 M Application Senders Code Senders ID 2/15

GS03 M Application Receiver’s Code See Duns in Supplement 2/15

GS04 M Date CCYYMMDD 8/8

GS05 M Time HHMM 4/4

GS06 M Group Control Number Must match the control number of the 1/9 GE02 element

GS07 M Responsibility Agency Code “X” Accredited Standards Committee X12 1/2

GS08 M Version/Release/Industry Identifier “005010X220” 1/12Code


6

ST – Transaction Set HeaderUsage : MandatorySegment Max UseWithin Loop : 1Loop Repeat : NONELoop ID : NONE

Example:ST*834*0001~


ST01 M Transaction Set Identifier Code “834” Eligibility coverage or benefit inquiry 3/3

ST02 M Transaction Set Control Number Identifying control number that must be 4/9unique within the transaction set functionalgroup assigned by the originator for atransaction set.

COMMENT: The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with the number, for example “0001”, and increment from there. This number must be unique within the specific group and interchanges, but can repeat in other groups and interchanges.

ST03 M Implementation Convention “005010X220” 1/35Reference


7

BGN – Beginning SegmentUsage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : NONELoop ID : NONE

Example:BGN*00*54321*20120101*1200****RX~


BGN01 M Purpose Code “00” Original Transmission 2/2

BGN02 M Reference Number 1/50

BGN03 M Date CCYYMMDD 8/8

BGN04 M Time HHMMSSUU/ HHMMSS/ HHMM 4/8

BGN05 NOT USED

BGN06 NOT USED

BGN07 NOT USED

BGN08 M Action Code “RX” Full enrollment with adds, terms and changes 1/2“2” Changes only./Update“4” Audit

BGN09 NOT USED

COMMENT: Files with an Action Code of “4” (Audit) should contain all active members, no changes or terminations. Audits should be sent periodically for groups that send update files on a regular basis.


8

N1 – Name (Sponsor)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 1000A

Example:N1*P5*ABC CORPORATION*FI*xxxxx1919~


N101 M Entity Identifier Code “P5” Plan Sponsor 2/2

N102 M Name Group Name 01/35

N103 M Identifier Code “FI” Fed Tax ID 2/2“ZZ” Mutually Defined

N104 M Identifier Organizational ID 2/80

N105 NOT USED

N106 NOT USED


9

N1 – Name (Payer) Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 1000B

Example:N1*IN*Delta Dental *FI*xxxxx4321~


N101 M Entity Identifier Code “IN” Insurer 2/2

N102 M Name See Name in Supplement 29/29

N103 M Identifier Code “FI” Fed Tax ID 2/2

N104 M Identifier See Federal Tax ID in Supplement 2/80

N105 NOT USED

N106 NOT USED


10

N1 – Name (TPA/Broker Name) Usage : Conditional Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 1000C

Example:N1*TV*XYZ Processing*FI*~


N101 M Entity Identifier Code “BO” Broker/ Sales Office 2/2“TV” Third Party Administrator(TPA)

N102 M Name TPA/Broker Name 1/60

N103 M Identifier Code “94” Organization Code 2/2“FI” Fed Tax ID“XV” HFCA Plan ID

N104 M Identifier Organizational ID 2/80

N105 NOT USED

N106 NOT USED


11

INS – Insured Benefit (Subscriber or Dependent)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : > 1Loop ID : 2000

Example:INS*Y*18*021**A~INS*N*19*001*AI*A****F~INS*N*19*001*AI*A*****Y~


INS01 M Yes/No Condition “Y” Subscriber 1/1 “N” Dependent

INS02 M Individual Relationship Code “01” Spouse 2/2“09” Adopted Child“18” Self“19” Child “25” Ex-Spouse

“53” Life Partner

INS03 M Maintenance Type Code “001” Change 3/3“021” Addition“024” Termination“030” Audit/No Change

INS04 O Maintenance Reason Code “03” Death 2/2 “04” Retirement

“11” Surviving Spouse“AI” No Reason Given

INS05 M Benefit Status Code “A” Active 1/1“C” COBRA“S” Surviving Spouse

INS06 O Medicare Plan Code “A” Medicare Part A 1/1“B” Medicare Part B“C” Medicare Part A and B“D” Medicare“E” No Medicare

INS07 NOT USED

INS08 O Employment Status Code “RT” Retired 2/2

INS09 O Student Status Code “F” Full-time 1/1“N” Not a Student“P” Part-time

INS10 O Handicap Status Indicator “Y” Yes, handicapped 1/1 “N” No, not handicapped

INS11 NOT USEDINS12 NOT USEDDelta DentalElectronic Data Interchange 834 Mapping Version 00501005/10/23

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INS13 NOT USEDINS14 NOT USEDINS15 NOT USEDINS16 NOT USEDINS17 NOT USED


13

REF – Reference Identification (Subscriber SSN)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:REF*0F*xxxxx6789~


REF01 M Reference ID Qualifier “0F” Subscriber Number Qualifier 2/2

REF02 M Reference Identification Subscriber Social Security Number 9/9

COMMENT: The social security must be 9 numeric digits. Alpha characters are not expected within the social security number REF02 element.

REF03 NOT USED

REF04 NOT USED


14

REF – Reference Identification (Subscriber Group Number)Usage : Conditional (This segment is required if the REF*1L segment is not sent in the HD loop) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:REF*1L*0005555~ (this is group number only)REF*1L*00055550001~ (this is group and subgroup number)REF*1L*0005555_0001~ (this is group and subgroup number)


REF01 M Reference ID Qualifier “1L” Group Number 2/2

REF02 M Reference Identification Group Number 7/12

COMMENT: The Group number must be 7 numeric digits. Alpha characters are not expected within the group number REF02 element. Your Group Administration analyst will furnish you with the group number(s).

COMMENT: The subgroup number may also be concatenated to the end of the group number or delimited with an agreed upon character (other than the three characters already being used for the segment terminator, element separator, repetition separator and sub-element separator) which separates the group and subgroup number.

REF03 NOT USED

REF04 NOT USED


15

REF – Reference Identification (Subscriber Subgroup Number)Usage : Conditional (This segment is required if the REF*17 segment is not sent in the HD loop)

(The Subgroup number may also be sent on the REF*1L group number seg) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:REF*17*0001~


REF01 M Reference ID Qualifier “17” Client Reporting Category 2/2

REF02 M Reference Identification Subgroup Number 4/5

COMMENT: Alpha characters are not expected within the subgroup number REF02 element. Your Group Administration analyst will furnish you with the subgroup number(s).

REF03 NOT USED

REF04 NOT USED


16

REF – Reference Identification (CAID)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:REF*23*987654321012345~


REF01 M Reference ID Qualifier “23” Client Number 2/2

REF02 M Reference Identification Customer Alternate ID 9/18

COMMENT: The Customer Alternate ID must be no more than 15 numeric digits. Alpha characters are not expected within the Customer Alternate ID REF02 element.

REF03 NOT USED

REF04 NOT USED


17

REF – Reference Identification (Subscriber Carrier ID)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:REF*DX*DDP~


REF01 M Reference ID Qualifier “DX” Department/Agency Number 2/2

REF02 M Reference Identification See Carrier ID in Supplement 4/6

REF03 NOT USED

REF04 NOT USED


18

DTP – Member Level Dates (Eligibility End)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:DTP*357*D8*20120101~


DTP01 M Date/Time Qualifier “357” Eligibility End 3/3

DTP02 M Date Time Period Format Qualifier “D8” Date Format CCYYMMDD 2/2

DTP03 M Date Eligibility End Date 8/8

COMMENT: If a termination is being sent and a 2300 loop is not provided with a benefit end date, this segment date is required. If a benefit end date is provided in the 2300 loop, the term date in the 2000 will be ignored. If a coverage is not specified in a 2300 loop, the termination date in the 2000 loop will be for all coverages.


19

DTP – Member Level Dates (Employment Date/Hire Date)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2000

Example:DTP*336*D8*19980301~


DTP01 M Date/Time Qualifier “336” Employment Begin 3/3


DTP03 M Date Hire Date 8/8

COMMENT: Segment is not sent for non-subscriber INS loops.


20

NM1 – Member Name (Subscriber or Dependent Name and SSN)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100A

Example:NM1*IL*1*DOE*JOHN*MAYNARD***34*xxxxx6789~

Min/Max


NM101 M Entity Identifier Code “IL” Subscriber / Dependent 2/2“74” Corrected Insured

NM102 M Entity Type Qualifier “1” Person (signifies this is a person) 1/1

NM103 M Last Name 1/24

NM104 M First Name 1/24

NM105 O Middle Name 1/24

NM106 NOT USED

NM107 NOT USED

NM108 O Identification Code Qualifier “34” SSN Qualifier 2/2

NM109 O Identification Code Individual SSN 9/9

COMMENT: The social security number must be 9 numeric digits. Alpha characters are not expected within the social security number NM109 element.

NM110 NOT USED

NM111 NOT USED

NM112 NOT USED


21

N3 – Address Information (Subscriber Address)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100A

Example:N3*123 ANY STREET*APT A~


N301 M Address Information Address Line 1 1/30

N302 O Address Information Address Line 2 1/30

COMMENT: The segment is mandatory for subscribers and optional for dependents.


22

N4 – Geographic Location (Subscriber City, State, Zip)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100A

Example:N4*ANY CITY*MI*xxxx99999~N4*TORONTO*ON*M2J4V2*CAN~


N401 M City Name Free Form Text of City 2/30

N402 O State or Province Code Code (Standard State/Province) as defined 2/2by appropriate government agency. See Appendix A.

COMMENT: N402 is required if the address is US or Canada.

N403 M Postal Code Zip Code 5/9

N404 O Country Code Code from ISO 3166 3/3

COMMENT: N404 is required if the N3 and N4 segments designate a foreign address.

N405 O Location Qualifier “CY” County/Parish 2/2

N406 O Location Identifier County code 2/3

N407 O Country Subdivision Code Code from Part 2 of ISO 3166 2/3


23

DMG – Demographic Information (Subscriber or Dependent)Usage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100A

Example:DMG*D8*19840713*M~


DMG01 M Date Time Period Format Qualifier “D8” Date Format CCYYMMDD 2/2

DMG02 M Date Birth Date 8/8

DMG03 M Gender Code “F” Female 1/1“M” Male“U” Unknown

DMG04 NOT USED

DMG05 NOT USED

DMG06 NOT USED

DMG07 NOT USED

DMG08 NOT USED

DMG09 NOT USED

DMG10 NOT USED

DMG11 NOT USED

COMMENT: The segment is mandatory for subscribers and dependents.


24

NM1 – Incorrect Member Name (Subscriber or Dependent Name and SSN)Usage : Conditional (Only required by DDMI if the Subscriber SSN is being changed) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100B

Example:NM1*70*1*DOE*JOHN*MAYNARD***34*xxxxx4321~

COMMENT: This segment should only be sent if the subscriber’s SSN is being changed. The prior incorrect SSN is sent on the NM109 element. This segment should only be sent on the subscriber INS loop.

Min/Max


NM101 M Entity Identifier Code “70” Prior Incorrect Insured 2/2





NM106 NOT USED

NM107 NOT USED

NM108 M Identification Code Qualifier “34” SSN Qualifier 2/2

NM109 M Identification Code Individual SSN 9/9

NM110 NOT USED

NM111 NOT USED

NM112 NOT USED


25

NM1 – Responsible Person (OBRA)Usage : Conditional Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2100B

Example:NM1*E1*1*DOE*JOHN*MAYNARD***34*xxxxx4321~

COMMENT: Used to identify the person other than the subscriber responsible for a child. Min/Max


NM101 M Entity Identifier Code “E1” QMSCO/OBRA 2/2





NM106 NOT USED

NM107 NOT USED

NM108 M Identification Code Qualifier “34” SSN Qualifier 2/2

NM109 M Identification Code Individual SSN 9/9

NM110 NOT USED

NM111 NOT USED

NM112 NOT USED


26

HD – Health CoverageUsage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2300

Example:HD*021**DEN~HD*001**DEN*30*FAM~


HD01 M Maintenance Type Code “001” Change 3/3“021” Addition“024” Cancellation or Termination“030” No change

HD02 NOT USED

HD03 M Insurance Line Code “DEN” Dental 3/3

HD04 O Plan Coverage Desc Group Program Type 2/50

COMMENT: HD04 is only required if the Group contract allows for Multiple Program Types. Your Group Administration analyst will furnish you with the Program Type(s) if necessary.

HD05 O Coverage Level Detail “E1D” Employee and 1 dependent 3/3“E5D” Employee and more than 1 dependent“EMP” Employee Only“ESP” Employee and Spouse“FAM” Employee, Spouse, and dependent(s)

COMMENT: HD05 is only required if the Group contract allows for Family Type Groups.

HD06 NOT USED

HD07 NOT USED

HD08 NOT USED

HD09 O Late Enrollment Indicator “Y” Late enrollee 1/1“N” Regular enrollee

HD10 NOT USED

HD11 NOT USED

COMMENT: The HD segment is required when adding coverage (INS code 021). For Full Files an HD segment is required for all employees not being terminated. The HD segment is optional for terminations if an Eligibility End Date was supplied in the 2000 loop.


27

DTP – Member Level Dates (Benefit Begin)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2300

Example:DTP*348*D8*20120101~


DTP01 M Date/Time Qualifier “348” Benefit Begin 3/3


DTP03 M Date Benefit Begin Date 8/8

COMMENT: Segment is required if HD01 = “021” or “030”


28

DTP – Member Level Dates (Benefit End)Usage : Conditional (see comment) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2300

Example:DTP*349*D8*20120201~


DTP01 M Date/Time Qualifier “349” Benefit End 3/3


DTP03 M Date Benefit End Date 8/8

COMMENT: Segment is required if HD01 = “024”

COMMENT: DTP03 should be the last date of actual coverage


29

REF – Health Coverage Policy (Subscriber Group Number)Usage : Conditional (This segment is required if the REF*1L segment is not sent in the INS loop) Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2300

Example:REF*1L*0005555~ (this is group number only)REF*1L*00055550001~ (this is group and subgroup number)REF*1L*0005555_0001~ (this is group and subgroup number)


REF01 M Reference ID Qualifier “1L” Group Number 2/2

REF02 M Reference Identification Group Number 7/12

COMMENT: The Group number must be 7 numeric digits. Alpha characters are not expected within the group number REF02 element.

COMMENT: The subgroup number may also be concatenated to the end of the group number or delimited with an agreed upon character which separates the group and subgroup number.

REF03 NOT USED

REF04 NOT USED


30

REF – Health Coverage Policy (Subscriber Subgroup Number)Usage : Conditional (This segment is required if the REF*17 segment is not sent in the INS loop)

(The subgroup number may also be sent on the REF*1L group number seg)Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : 2300

Example:REF*17*0001~


REF01 M Reference ID Qualifier “17” Client Reporting Category 2/2

REF02 M Reference Identification Subgroup Number 4/5

COMMENT: Alpha characters are not expected within the subgroup number REF02 element. Your Group Administration analyst will furnish you with the subgroup number(s).

REF03 NOT USED

REF04 NOT USED


31

SE – Transaction Set TrailerUsage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : NONELoop ID : NONE

Example:SE*19*12345~


SE01 M Number of Segments Included Total number of segments included in a 1/10transaction set including ST and SE

SE02 M Transaction Set Control Number 4 to 9 digit control number. 4/9Must match Transaction Set Control Number in ST02.


32

GE – Functional Group TrailerUsage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : NONE

Example:GE*1*xxxxx0001~


GE01 M Number of Transaction Total number of transaction sets included in 1/6the functional group.

GE02 M Transaction Set Control Number 1 to 9 digit control number. Must match 1/9 Functional Group Control Number in GS06.


33

IEA – Interchange Control TrailerUsage : Mandatory Segment Max UseWithin Loop : 1Loop Repeat : 1Loop ID : NONE

Example:IEA*1*000000001*~


IEA01 M Number of Included Functional Groups Total number of functional groups included 1/5in the Interchange.

IEA02 M Interchange Control Number 9 digit control number. Must match 9/9 Interchange Control Number in ISA13.


34

834 Full File Transaction Example

Scenario #1Company 1 is sending a full file of all covered Subscribers and dependents. For purposes of this example, company 1 has 1 employee with a spouse. Also, a dependent is being terminated under that 1 employee.

Sown in the example is the following;Subscriber is John Paul Doe, DOB June 10 1940, SSN = xxxxx3333, benefit begin Date for Eligibility is August 1 1989Spouse is Jane M Doe, DOB July 15 1945, SSN = xxxxx4444, benefit begin Date for Eligibility is March 1 1999Dependent Mark Doe is being terminated effective July 1, 2002

ISA*00* *00* *ZZ*067999979 *01*xxxxx6789 *120101*0915*^*00501*xxxx00745*0*P*>~GS*BE*C1591*xxxxx1234*201201011*0916*2304*X*005010X220~ST*834*12345~BGN*00*ABCDE12456*20000815*0100****RX~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*021**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19890801~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~HD*021**DEN~DTP*348*D8*19890801~INS*N*01*021**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~NM1*IL*1*DOE*JANE*M***34*xxxxx4444~DMG*D8*19450715*F~HD*021**DEN~DTP*348*D8*19990301~INS*N*01*024**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~NM1*IL*1*DOE*MARK****34*xxxxx4444~DMG*D8*19790515*M~HD*024**DEN~DTP*349*D8*20020701~SE*35*12345~GE*1*2304~IEA*1*xxxxx0745~


35

834 Maintenance Transaction Examples

Scenario #1Add a Subscriber and SpouseSubscriber is John P Doe, DOB June 10 1940, SSN = xxxxx3333Spouse is Jane M Doe, DOB July 15 1945, SSN = xxxxx4444Benefit begin Date for both is is May 1 1996

ISA*00* *00* *ZZ*067999979 *01*xxxxx1234 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx01234*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*021**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~HD*021**DEN~DTP*348*D8*19960501~INS*N*01*021**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~NM1*IL*1*DOE*JANE*M***34*xxxxx4444~DMG*D8*19450715*F~HD*021**DEN~DTP*348*D8*19960501~SE*26*12345~GE*1*2304~IEA*1*xxxxx0745~


36

834 Maintenance Transaction Examples (cont’d)

Scenario #2Terminate Subscriber with a benefit end date of May 1, 2002Subscriber is John P Doe, DOB June 10 1940, SSN = xxxxx3333

ISA*00* *00* *ZZ*067999979 *01*xxxxx1234 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx1234*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*024**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~HD*024**DEN~DTP*349*D8*20020501~SE*17*12345~GE*1*2304~IEA*1*xxxxx0745~

Termination without sending an HD would also be valid as shown below (this would terminate all insurance coverages i.e. dental, vision, medical):

ISA*00* *00* *ZZ*067999979 *01*xxxxx1234 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx1234*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*024**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~DTP*357*D8*20020501~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~SE*16*12345~GE*1*2304~IEA*1*xxxxx0745~


37


Scenario #3Change the Group and Subgroup to which a subscriber belongs. This will require a Termination of the Subscriber and Add of the Subscriber.Subscriber is John P Doe, DOB June 10 1940, SSN = xxxxx3333.

ISA*00* *00* *ZZ*067999979 *01*xxxxx1234 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx1234*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*024**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~HD*024**DEN~DTP*349*D8*20020501~INS*Y*18*021**A~REF*0F*xxxxx3333~REF*1L*0006666~REF*17*0002~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 Any St*Apt.A~N4*Any Town*MI*48111~DMG*D8*19400610*M~HD*021**DEN~DTP*348*D8*20020501~SE*29*12345~GE*1*2304~IEA*1*xxxxx0745~


38


Scenario #4

Subscriber is John P Doe, DOB June 10 1940, SSN = xxxxx3333 has moved his residence to a new location

ISA*00* *00* *ZZ*067999979 *01*xxxxx1234 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx1234*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*001**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 THAT ST*APT.B~N4*THAT TOWN*MI*4899~DMG*D8*19400610*M~HD*001**DEN~DTP*303*D8*20020501~SE*17*12345~GE*1*2304~IEA*1*xxxxx0745~

Change without sending an HD would also be valid as shown below (this would change all insurance coverages i.e. dental, vision, medical):

ISA*00* *00* *ZZ*067999979 *01*xxxxx4622 *000821*0915*^*00501*xxxxx0745*0*P*>~GS*BE*C1591*xxxxx4622*20020821*0916*2304*X*005010X220~ST*834*12345*005010X220~BGN*00*ABCDE12456*20000815*0100****2~N1*P5*ABC CORP*FI*xxxxx7777~N1*IN*DELTA DENTAL*FI*xxxxx4321~INS*Y*18*001**A~REF*0F*xxxxx3333~REF*1L*0005555~REF*17*0001~REF*DX*DDPM~DTP*336*D8*19960301~NM1*IL*1*DOE*JOHN*PAUL***34*xxxxx3333~N3*100 THAT ST*APT.B~N4*THAT TOWN*MI*4899~DMG*D8*19400610*M~SE*15*12345~GE*1*2304~IEA*1*xxxxx0745~


39

APPENDIX A

US STATE/TERRITORY CODES

AK - ALASKAAL – ALABAMAAR – ARKANSASAS – AMERICAN SAMOAAZ – ARIZONACA – CALIFORNIACO – COLORADOCT – CONNECTICUTDC – DISTRICT OF COLUMBIADE – DELAWAREFL - FLORIDAFM – MICRONESIAGA – GEORGIAGU – GUAMHI – HAWAIIIA – IOWAID – IDAHOIL – ILLINOISIN – INDIANAKS – KANSASKY – KENTUCKYLA – LOUISIANAMA – MASSACHUSETTSMD – MARYLANDME – MAINEMH – MARSHALL ISLANDSMI – MICHIGANMN – MINNESOTAMO – MISSOURIMP – NORTHERN MARIANA ISLANDSMS – MISSISSIPPIMT – MONTANANC – NORTH CAROLINAND – NORTH DAKOTANE – NEBRASKANH – HEW HAMPSHIRENJ – NEW JERSEYNM – NEW MEXICONV – NEVADANY – NEW YORKOH – OHIOOK – OKLAHOMAOR – OREGONPA – PENNSYLVANIAPR – PUERTO RICOPW – PALAURI – RHODE ISLANDSC – SOUTH CAROLINASD – SOUTH DAKOTATN – TENNESSEETX – TEXASUT – UTAHVA – VIRGINIAVI – VIRGIN ISLANDSVT – VERMONTWA – WASHINGTONWI – WISCONSINWV – WEST VIRGINIAWY – WYOMING


40

APPENDIX A(continued)

CANADIAN PROVINCE CODES

AB – ALBERTABC – BRITISH COLUMBIALB – LABRADORMB – MANITOBANB – BRUNSWICKNF – NEWFOUNDLANDNS – NOVA SCOTIANT – NORTHWEST TERRITORIESON – ONTARIOPE – PRINCE EDWARD ISLANDQC – QUEBECSK – SASKATCHEWANYT – YUKON TERRITORY


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