834 Benefit Enrollment and Maintenance 5010...LS Loop Additional Reporting Categories ... 2/0200 The...

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834 Benefit Enrollment and Maintenance 5010 HIPAA/V5010X220/834: 834 Benefit Enrollment and Maintenance

Companion Guide Version 1.0

5/11/2011 Benefit Enrollment and Maintenance - 834

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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

Benefit Enrollment and Maintenance - 834

iii

LX Member Reporting Categories .............................................................................................................................. 82

2750 Loop Reporting Category ....................................................................................................................................... 83

N1 Reporting Category ................................................................................................................................................ 84

REF Reporting Category Reference .............................................................................................................................. 85

DTP Reporting Category Date ....................................................................................................................................... 86

LE Additional Reporting Categories Loop Termination ........................................................................................... 87

SE Transaction Set Trailer .......................................................................................................................................... 88

GE Functional Group Trailer ....................................................................................................................................... 89

IEA Interchange Control Trailer .................................................................................................................................. 90


1

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 Segment Name Req Max Use Repeat Notes Usage

ISA Interchange Control Header M 1 Required

GS Functional Group Header M 1 Required

Heading: Pos Id Segment Name Req Max Use Repeat Notes Usage

0100 ST Transaction Set Header M 1 Required

0200 BGN Beginning Segment M 1 Required

0300 REF Transaction Set Policy

Number

O 1 Situational

0400 DTP File Effective Date O >1 Situational

LOOP ID - 1000A 1 N1/0700L

0700 N1 Sponsor Name M 1 N1/0700 Required

LOOP ID - 1000B 1 N1/0700L

0700 N1 Payer M 1 N1/0700 Required

LOOP ID - 1000C 2 N1/0700L

0700 N1 TPA/Broker Name O 1 N1/0700 Situational

LOOP ID - 1100C 1

1200 ACT TPA/Broker Account

Information

O 1 Situational

Detail: Pos Id Segment Name Req Max Use Repeat Notes Usage

LOOP ID - 2000 >1 N2/0100L

0100 INS Member Level Detail O 1 N2/0100 Required

0200 REF Subscriber Identifier M 1 N2/0200 Required

0200 REF Member Policy Number O 1 N2/0200 Situational

0200 REF Member Supplemental

Identifier

O 13 N2/0200 Situational

0250 DTP Member Level Dates O 24 Situational

LOOP ID - 2100A 1

0300 NM1 Member Name O 1 Required

0400 PER Member Communications

Numbers

O 1 Situational

0500 N3 Member Residence Street

Address

O 1 Situational

0600 N4 Member City, State, ZIP Code O 1 Required

0800 DMG Member Demographics O 1 Situational


2

1000 EC Employment Class O >1 Situational

LOOP ID - 2300 99

2600 HD Health Coverage O 1 Situational

2700 DTP Health Coverage Dates O 6 Required

2800 AMT Health Coverage Policy O 9 Situational

2900 REF Health Coverage Policy

Number

O 14 Situational

2900 REF Prior Coverage Months O 1 Situational

LOOP ID - 2310 30 N2/3100L

3100 LX Provider Information O 1 N2/3100 Situational

3200 NM1 Provider Name O 1 N2/3200 Required

3500 N3 Provider Address O 2 Situational

3600 N4 Provider City, State, ZIP Code O 1 Required

3700 PER Provider Communications

Numbers

O 2 Situational

3950 PLA Provider Change Reason O 1 Situational

LOOP ID - 2320 5

4000 COB Coordination of Benefits O 1 Situational

4050 REF Additional Coordination of

Benefits Identifiers

O 4 Situational

4070 DTP Coordination of Benefits

Eligibility Dates

O 2 Situational

LOOP ID - 2330 3

4100 NM1 Coordination of Benefits

Related Entity

O 1 Situational

4300 N3 Coordination of Benefits

Related Entity Address

O 1 Situational

4400 N4 Coordination of Benefits Other

Insurance Company City,

State, ZIP Code

O 1 Required

4500 PER Administrative

Communications Contact

O 1 Situational

LOOP ID - 2500 5 N2/5500L

5500 FSA Flexible Spending Account O 1 N2/5500 Situational

5600 AMT Monetary Amount Information O 10 Situational

5700 DTP Date or Time or Period O 10 Situational

5750 REF Reference Information O >1 Situational

LOOP ID - LS 1

6880 LS Additional Reporting

Categories

O 1 Situational

LOOP ID - 2700 >1

6881 LX Member Reporting Categories O 1 Situational

LOOP ID - 2750 1

6882 N1 Reporting Category M 1 Situational

6883 REF Reporting Category Reference M 16 Situational

6884 DTP Reporting Category Date O 1 Situational

6885 LE Additional Reporting

Categories Loop Termination

O 1 Situational

6900 SE Transaction Set Trailer M 1 Required

Not Defined: Pos Id Segment Name Req Max Use Repeat Notes Usage

GE Functional Group Trailer M 1 Required


3

IEA Interchange Control Trailer M 1 Required

Notes: 1/0700L At least one iteration of loop 1000 is required to identify the sender or receiver.

1/0700 At least one iteration of loop 1000 is required to identify the sender or receiver.

1/0700L At least one iteration of loop 1000 is required to identify the sender or receiver.


1/0700L At least one iteration of loop 1000 is required to identify the sender or receiver.


2/0100L 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.



2/3100L 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.


4

ISA Interchange Control Header 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 Id Element Name Req Type Min/Max Usage

ISA01 I01 Authorization Information Qualifier M ID 2/2 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 Authorization Information M 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 Security Information Qualifier M 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 Security Information M 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 Interchange ID Qualifier M ID 2/2 Required

Description: Code indicating the system/method of code structure used to designate the sender or

receiver ID element being qualified


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 Interchange Sender ID M 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 Interchange ID Qualifier M ID 2/2 Required

Description: Code indicating the system/method of code structure used to designate the sender or

receiver ID element being qualified


Code Name


5

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

ISA08 I07 Interchange Receiver ID M 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

Description: Date of the interchange

ISA10 I09 Interchange Time M TM 4/4 Required

Description: Time of the interchange

ISA11 I65 Repetition Separator M 1/1 Required

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


Code Name

00501 Standards Approved for Publication by ASC X12 Procedures Review Board through

October 2003

ISA13 I12 Interchange Control Number M N0 9/9 Required

Description: A control number assigned by the interchange sender

ISA14 I13 Acknowledgment Requested M ID 1/1 Required

Description: Code indicating sender's request for an interchange acknowledgment


ISA15 I14 Interchange Usage Indicator M ID 1/1 Required

Description: Code indicating whether data enclosed by this interchange envelope is test, production

or information


Code Name

P Production Data

T Test Data

ISA16 I15 Component Element Separator M 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


6

BCI Requirements:

ISA01 IS REQUIRED AND SHOULD CONTAIN "00"



ISA04 IS REQUIRED AND SHOULD CONTAIN "<BLANK>"


ISA06 IS REQUIRED AND SHOULD CONTAIN "<THE FED TAX ID OF THE

SENDER>"



ISA09 IS REQUIRED AND SHOULD CONTAIN "<YYMMDD>"

ISA10 IS REQUIRED AND SHOULD CONTAIN <HHMM>

ISA11 IS REQUIRED AND SHOULD CONTAIN "^"


ISA13 IS REQUIRED AND SHOULD CONTAIN "<Unique Number>"


ISA15 IS REQUIRED AND SHOULD CONTAIN "<P or T >"

ISA16 IS REQUIRED AND SHOULD CONTAIN ">"

ELEMENT SEPARATOR *

TERMINATOR DELIMITER ~


7

GS Functional Group Header Pos: Max: 1




Purpose: To indicate the beginning of a functional group and to provide control information


GS01 479 Functional Identifier Code M ID 2/2 Required

Description: Code identifying a group of application related transaction sets


Code Name

BE Benefit Enrollment and Maintenance (834)

GS02 142 Application Sender's Code M AN 2/15 Required

Description: Code identifying party sending transmission; codes agreed to by trading partners

GS03 124 Application Receiver's Code M AN 2/15 Required

Description: Code identifying party receiving transmission; codes agreed to by trading partners

GS04 373 Date M DT 8/8 Required

Description: Date expressed as CCYYMMDD where CC represents the first two digits of the

calendar year

GS05 337 Time M 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 Group Control Number M N0 1/9 Required

Description: Assigned number originated and maintained by the sender

GS07 455 Responsible Agency Code M ID 1/2 Required

Description: Code identifying the issuer of the standard; this code is used in conjunction with Data

Element 480


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


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


8

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"


9

ST Transaction Set Header Pos: 0100 Max: 1

Heading - Mandatory



Purpose: To indicate the start of a transaction set and to assign a control number


ST01 143 Transaction Set Identifier Code M ID 3/3 Required

Description: Code uniquely identifying a Transaction Set


Code Name

834 Benefit Enrollment and Maintenance

ST02 329 Transaction Set Control Number M 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

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"


10

BGN Beginning Segment Pos: 0200 Max: 1

Heading - Mandatory



Purpose: To indicate the beginning of a transaction set


BGN01 353 Transaction Set Purpose Code M ID 2/2 Required

Description: Code identifying purpose of transaction set


Code Name

00 Original

15 Re-Submission

22 Information Copy

BGN02 127 Reference Identification M AN 1/50 Required

Description: Reference information as defined for a particular Transaction Set or as specified by the

Reference Identification Qualifier

BGN03 373 Date M DT 8/8 Required


calendar year

BGN04 337 Time X 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 Time Code O 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


BGN06 127 Reference Identification O AN 1/50 Situational



BGN08 306 Action Code O ID 1/2 Required

Description: Code indicating type of action


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.


11

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


12

REF Transaction Set Policy Number Pos: 0300 Max: 1

Heading - Optional


User Option (Usage): Situational

Purpose: To specify identifying information


REF01 128 Reference Identification Qualifier M ID 2/3 Required

Description: Code qualifying the Reference Identification


Code Name

38 Master Policy Number

REF02 127 Reference Identification X AN 1/50 Required



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


13

DTP File Effective Date Pos: 0400 Max: >1

Heading - Optional



Purpose: To specify any or all of a date, a time, or a time period


DTP01 374 Date/Time Qualifier M ID 3/3 Required

Description: Code specifying type of date or time, or both date and time


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


Code Name

D8 Date Expressed in Format CCYYMMDD

DTP03 1251 Date Time Period M 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 "007"

DTP02 IS REQUIRED AND SHOULD CONTAIN "D8"

DTP03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"


14

Loop Sponsor Name Pos: 0700 Repeat: 1

Mandatory

Loop: 1000A Elements: N/A


Purpose: To identify a party by type of organization, name, and code

Loop Summary: Pos Id Segment Name Req Max Use Repeat Usage

0700 N1 Sponsor Name M 1 Required


15

N1 Sponsor Name Pos: 0700 Max: 1

Heading - Mandatory

Loop: 1000A Elements: 4




N101 98 Entity Identifier Code M ID 2/3 Required

Description: Code identifying an organizational entity, a physical location, property or an individual


Code Name

P5 Plan Sponsor

N102 93 Name X AN 1/60 Situational

Description: Free-form name

N103 66 Identification Code Qualifier X ID 1/2 Required

Description: Code designating the system/method of code structure used for Identification Code (67)


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 Identification Code X 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


16

Loop Payer Pos: 0700 Repeat: 1

Mandatory

Loop: 1000B Elements: N/A




0700 N1 Payer M 1 Required


17

N1 Payer Pos: 0700 Max: 1

Heading - Mandatory

Loop: 1000B Elements: 4







Code Name

IN Insurer

N102 93 Name X AN 1/60 Situational





Code Name



XV Centers for Medicare and Medicaid Services PlanID


Description: Code identifying a party or other code

ExternalCodeList

Name: 540

Description: Centers for Medicare and Medicaid Services PlanID






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


18

Loop TPA/Broker Name Pos: 0700 Repeat: 2

Optional

Loop: 1000C Elements: N/A




0700 N1 TPA/Broker Name O 1 Situational

1200 Loop 1100C O 1 Situational


19

N1 TPA/Broker Name Pos: 0700 Max: 1

Heading - Optional

Loop: 1000C Elements: 4







Code Name

BO Broker or Sales Office

TV Third Party Administrator (TPA)

N102 93 Name X AN 1/60 Required





Code Name






ExternalCodeList

Name: 540








20

Loop TPA/Broker Account Information Pos: 1200 Repeat: 1

Optional

Loop: 1100C Elements: N/A


Purpose: To specify account information


1200 ACT TPA/Broker Account Information O 1 Situational


21

ACT TPA/Broker Account

Information

Pos: 1200 Max: 1

Heading - Optional

Loop: 1100C Elements: 2


Purpose: To specify account information


ACT01 508 Account Number M AN 1/35 Required

Description: Account number assigned

ACT06 508 Account Number X AN 1/35 Situational


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.


22

Loop Member Level Detail Pos: 0100 Repeat: >1

Optional

Loop: 2000 Elements: N/A


Purpose: To provide benefit information on insured entities


0100 INS Member Level Detail O 1 Required

0200 REF Subscriber Identifier M 1 Required

0200 REF Member Policy Number O 1 Situational

0200 REF Member Supplemental Identifier O 13 Situational

0250 DTP Member Level Dates O 24 Situational

0300 Loop 2100A O 1 Required

2600 Loop 2300 O 99 Situational


6880 Loop LS O 1 Situational


23

INS Member Level Detail Pos: 0100 Max: 1

Detail - Optional

Loop: 2000 Elements: 14


Purpose: To provide benefit information on insured entities


INS01 1073 Yes/No Condition or Response Code M ID 1/1 Required

Description: Code indicating a Yes or No condition or response


Code Name

N No

Y Yes

INS02 1069 Individual Relationship Code M ID 2/2 Required

Description: Code indicating the relationship between two individuals or entities


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 Maintenance Type Code O ID 3/3 Required

Description: Code identifying the specific type of item maintenance



24

Code Name

001 Change

021 Addition

024 Cancellation or Termination

025 Reinstatement

030 Audit or Compare

INS04 1203 Maintenance Reason Code O ID 2/3 Situational

Description: Code identifying the reason for the maintenance change


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


25

AJ Appointment Times not Met in a Timely Manner

AL Algorithm Assigned Benefit Selection

EC Member Benefit Selection

XN Notification Only

XT Transfer

INS05 1216 Benefit Status Code O ID 1/1 Required

Description: The type of coverage under which benefits are paid


Code Name

A Active

C Consolidated Omnibus Budget Reconciliation Act (COBRA)

S Surviving Insured

T Tax Equity and Fiscal Responsibility Act (TEFRA)

INS06 C052 Medicare Status Code O Comp Situational

Description: To provide Medicare coverage and associated reason for Medicare eligibility

INS06-01 1218 Medicare Plan Code M ID 1/1 Required

Description: Code identifying the Medicare Plan


INS06-02 1701 Eligibility Reason Code O ID 1/1 Situational

Description: Code specifying reason for eligibility


INS07 1219 Consolidated Omnibus Budget

Reconciliation Act (COBRA) Qualifying

Event Code

O ID 1/2 Situational

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 Employment Status Code O ID 2/2 Situational

Description: Code showing the general employment status of an employee/claimant


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


26

INS09 1220 Student Status Code O 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


INS10 1073 Yes/No Condition or Response Code O ID 1/1 Situational



Code Name

N No

Y Yes

INS11 1250 Date Time Period Format Qualifier X ID 2/3 Situational



Code Name


INS12 1251 Date Time Period X AN 1/35 Situational


INS13 1165 Confidentiality Code O ID 1/1 Situational

Description: Code indicating the access to insured information


Code Name

R Restricted Access

U Unrestricted Access

INS17 1470 Number O N0 1/9 Situational

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


27

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


28

REF Subscriber Identifier Pos: 0200 Max: 1

Detail - Mandatory








Code Name

0F Subscriber Number






BCI Requirements:

REF01 IS REQUIRED AND SHOULD CONTAIN "0F"

REF02 IS REQUIRED AND SHOULD CONTAIN "<SSN>"

REF03 IS NOT USED

REF04 IS NOT USED


29

REF Member Policy Number Pos: 0200 Max: 1

Detail - Optional








Code Name

1L Group or Policy Number






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


30

REF Member Supplemental

Identifier

Pos: 0200 Max: 13

Detail - Optional








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




ExternalCodeList

Name: 307

Description: National Council for Prescription Drug Programs Pharmacy Number



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


31

REF04 IS NOT USED


32

DTP Member Level Dates Pos: 0250 Max: 24

Detail - Optional








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


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




Code Name





BCI Requirements:

DTP01 IS REQUIRED AND SHOULD CONTAIN "<336 &337>"


33

DPT02 IS REQUIRED AND SHOULD CONTAIN "D8"

DPT03 IS REQUIRED AND SHOULD CONTAIN "<CCYYMMDD>"

DPT01 IS REQUIRED AND SHOULD CONTAIN "<356 & 357>"




34

Loop Member Name Pos: 0300 Repeat: 1

Optional

Loop: 2100A Elements: N/A


Purpose: To supply the full name of an individual or organizational entity


0300 NM1 Member Name O 1 Required

0400 PER Member Communications Numbers O 1 Situational

0500 N3 Member Residence Street Address O 1 Situational

0600 N4 Member City, State, ZIP Code O 1 Required

0800 DMG Member Demographics O 1 Situational

1000 EC Employment Class O >1 Situational


35

NM1 Member Name Pos: 0300 Max: 1

Detail - Optional





NM101 98 Entity Identifier Code M ID 2/3 Required



Code Name

74 Corrected Insured

IL Insured or Subscriber

NM102 1065 Entity Type Qualifier M ID 1/1 Required

Description: Code qualifying the type of entity


Code Name

1 Person

NM103 1035 Name Last or Organization Name X AN 1/60 Required

Description: Individual last name or organizational name

NM104 1036 Name First O AN 1/35 Situational

Description: Individual first name

NM105 1037 Name Middle O AN 1/25 Situational

Description: Individual middle name or initial

NM106 1038 Name Prefix O AN 1/10 Situational

Description: Prefix to individual name

NM107 1039 Name Suffix O AN 1/10 Situational

Description: Suffix to individual name

NM108 66 Identification Code Qualifier X ID 1/2 Situational



Code Name

34 Social Security Number

ZZ Mutually Defined

NM109 67 Identification Code X AN 2/80 Situational


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.


Semantics: 1. NM102 qualifies NM103.


36

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>"


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


37

PER Member Communications

Numbers

Pos: 0400 Max: 1

Detail - Optional



Purpose: To identify a person or office to whom administrative communications should be directed


PER01 366 Contact Function Code M ID 2/2 Required

Description: Code identifying the major duty or responsibility of the person or group named


Code Name

IP Insured Party

PER03 365 Communication Number Qualifier X ID 2/2 Required

Description: Code identifying the type of communication number


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 Communication Number X AN 1/256 Required

Description: Complete communications number including country or area code when applicable

PER05 365 Communication Number Qualifier X ID 2/2 Situational



Code Name


BN Beeper Number

CP Cellular Phone

EM Electronic Mail


FX Facsimile


TE Telephone


PER06 364 Communication Number X AN 1/256 Situational





Code Name


38


BN Beeper Number

CP Cellular Phone

EM Electronic Mail


FX Facsimile


TE Telephone




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.


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


39

N3 Member Residence Street

Address

Pos: 0500 Max: 1

Detail - Optional



Purpose: To specify the location of the named party


N301 166 Address Information M AN 1/55 Required

Description: Address information

N302 166 Address Information O AN 1/55 Situational


BCI Requirements:

N301 IS REQUIRED AND SHOULD CONTAIN "<Address Line 1>"

N302 IS SITUATIONAL AND SHOULD CONTAIN "<Address Line 2>"


40

N4 Member City, State, ZIP Code Pos: 0600 Max: 1

Detail - Optional



Purpose: To specify the geographic place of the named party


N401 19 City Name O AN 2/30 Required

Description: Free-form text for city name

N402 156 State or Province Code X ID 2/2 Situational

Description: Code (Standard State/Province) as defined by appropriate government agency

ExternalCodeList

Name: 22

Description: States and Provinces

N403 116 Postal Code O 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

Description: Code identifying the country

ExternalCodeList

Name: 5

Description: Countries, Currencies and Funds

N405 309 Location Qualifier X ID 1/2 Situational

Description: Code identifying type of location


Code Name

60 Area

CY County/Parish

N406 310 Location Identifier O AN 1/30 Situational

Description: Code which identifies a specific location

N407 1715 Country Subdivision Code X ID 1/3 Situational

Description: Code identifying the country subdivision

ExternalCodeList

Name: 5


Syntax Rules: 1. E0207 - Only one of N402 or N407 may be present.

2. C0605 - If N406 is present, then N405 is required.



41

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>"


42

DMG Member Demographics Pos: 0800 Max: 1

Detail - Optional



Purpose: To supply demographic information


DMG01 1250 Date Time Period Format Qualifier X ID 2/3 Required



Code Name


DMG02 1251 Date Time Period X AN 1/35 Required


DMG03 1068 Gender Code O ID 1/1 Required

Description: Code indicating the sex of the individual


Code Name

F Female

M Male

U Unknown

DMG04 1067 Marital Status Code O ID 1/1 Situational

Description: Code defining the marital status of a person


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 Race or Ethnicity Code O 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


Code Name

7 Not Provided

8 Not Applicable

A Asian or Pacific Islander

B Black

C Caucasian


43

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

DMG05-02 1270 Code List Qualifier Code X ID 1/3 Situational

Description: Code identifying a specific industry code list


Code Name

RET Classification of Race or Ethnicity

DMG05-03 1271 Industry Code X AN 1/30 Situational

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

Description: Code indicating citizenship status


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 X ID 1/3 Situational

Description: Code identifying a specific industry code list


Code Name

REC Race or Ethnicity Collection Code

DMG11 1271 Industry Code X AN 1/30 Situational

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:


44

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>"


DMG07 IS NOT USED

DMG08 IS NOT USED

DMG09 IS NOT USED



45

EC Employment Class Pos: 1000 Max: >1

Detail - Optional



Purpose: To provide class of employment information


EC01 1176 Employment Class Code O ID 2/3 Required

Description: Code indicating category of employee


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 Employment Class Code O ID 2/3 Situational



Code Name

01 Union

02 Non-Union

03 Executive

04 Non-Executive

05 Management

06 Non-Management

07 Hourly

08 Salaried

09 Administrative


11 Exempt

12 Non-Exempt


18 Key-Employee

19 Bargaining

20 Non-Bargaining

21 Owner


46

22 President

23 Vice President

EC03 1176 Employment Class Code O ID 2/3 Situational



Code Name

01 Union

02 Non-Union

03 Executive

04 Non-Executive

05 Management

06 Non-Management

07 Hourly

08 Salaried

09 Administrative


11 Exempt

12 Non-Exempt


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.


47

Loop Health Coverage Pos: 2600 Repeat: 99

Optional



Purpose: To provide information on health coverage


2600 HD Health Coverage O 1 Situational

2700 DTP Health Coverage Dates O 6 Required

2800 AMT Health Coverage Policy O 9 Situational

2900 REF Health Coverage Policy Number O 14 Situational

2900 REF Prior Coverage Months O 1 Situational




48

HD Health Coverage Pos: 2600 Max: 1

Detail - Optional



Purpose: To provide information on health coverage


HD01 875 Maintenance Type Code M ID 3/3 Required



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 Insurance Line Code O ID 2/3 Required

Description: Code identifying a group of insurance products


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 Plan Coverage Description O AN 1/50 Situational

Description: A description or number that identifies the plan or coverage

HD05 1207 Coverage Level Code O ID 3/3 Situational

Description: Code indicating the level of coverage being provided for this insured


49


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



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


50

DTP Health Coverage Dates Pos: 2700 Max: 6

Detail - Optional








Code Name

300 Enrollment Signature Date


343 Premium Paid to Date End

348 Benefit Begin

349 Benefit End

543 Last Premium Paid Date

695 Previous Period




Code Name


RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD




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>"


51

AMT Health Coverage Policy Pos: 2800 Max: 9

Detail - Optional



Purpose: To indicate the total monetary amount


AMT01 522 Amount Qualifier Code M ID 1/3 Required

Description: Code to qualify amount


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 Monetary Amount M R 1/18 Required

Description: Monetary amount


52

REF Health Coverage Policy

Number

Pos: 2900 Max: 14

Detail - Optional








Code Name


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






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


53

REF Prior Coverage Months Pos: 2900 Max: 1

Detail - Optional








Code Name

QQ Unit Number







54

Loop Provider Information Pos: 3100 Repeat: 30

Optional



Purpose: To reference a line number in a transaction set


3100 LX Provider Information O 1 Situational

3200 NM1 Provider Name O 1 Required

3500 N3 Provider Address O 2 Situational

3600 N4 Provider City, State, ZIP Code O 1 Required

3700 PER Provider Communications Numbers O 2 Situational

3950 PLA Provider Change Reason O 1 Situational


55

LX Provider Information Pos: 3100 Max: 1

Detail - Optional





LX01 554 Assigned Number M N0 1/6 Required

Description: Number assigned for differentiation within a transaction set

BCI Requirements:

LX01 SHOULD CONTAIN "1"


56

NM1 Provider Name Pos: 3200 Max: 1

Detail - Optional








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




Code Name

1 Person

2 Non-Person Entity

NM103 1035 Name Last or Organization Name X AN 1/60 Situational


NM104 1036 Name First O AN 1/35 Situational

Description: Individual first name

NM105 1037 Name Middle O AN 1/25 Situational

Description: Individual middle name or initial

NM106 1038 Name Prefix O AN 1/10 Situational

Description: Prefix to individual name

NM107 1039 Name Suffix O AN 1/10 Situational

Description: Suffix to individual name




Code Name

34 Social Security Number


SV Service Provider Number

XX Centers for Medicare and Medicaid Services National Provider Identifier



57


ExternalCodeList

Name: 537

Description: Centers for Medicare and Medicaid Services National Provider Identifier

NM110 706 Entity Relationship Code X ID 2/2 Required

Description: Code describing entity relationship


Code Name

25 Established Patient

26 Not Established Patient

72 Unknown







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>"





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


58

N3 Provider Address Pos: 3500 Max: 2

Detail - Optional










59

N4 Provider City, State, ZIP Code Pos: 3600 Max: 1

Detail - Optional









ExternalCodeList

Name: 22




for United States)

ExternalCodeList

Name: 932


ExternalCodeList

Name: 51




ExternalCodeList

Name: 5




ExternalCodeList

Name: 5








60

PER Provider Communications

Numbers

Pos: 3700 Max: 2

Detail - Optional








Code Name

IC Information Contact




Code Name


BN Beeper Number

CP Cellular Phone

EM Electronic Mail


FX Facsimile


TE Telephone







Code Name


BN Beeper Number

CP Cellular Phone

EM Electronic Mail


FX Facsimile


TE Telephone







Code Name


61


BN Beeper Number

CP Cellular Phone

EM Electronic Mail


FX Facsimile


TE Telephone








62

PLA Provider Change Reason Pos: 3950 Max: 1

Detail - Optional



Purpose: To indicate action to be taken for the location specified and to qualify the location specified


PLA01 306 Action Code M ID 1/2 Required

Description: Code indicating type of action


Code Name

2 Change (Update)

PLA02 98 Entity Identifier Code M ID 2/3 Required



Code Name

1P Provider

PLA03 373 Date M DT 8/8 Required


calendar year

PLA05 1203 Maintenance Reason Code O ID 2/3 Required



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.


63

Loop Coordination of Benefits Pos: 4000 Repeat: 5

Optional



Purpose: To supply information on coordination of benefits


4000 COB Coordination of Benefits O 1 Situational

4050 REF Additional Coordination of Benefits Identifiers O 4 Situational

4070 DTP Coordination of Benefits Eligibility Dates O 2 Situational



64

COB Coordination of Benefits Pos: 4000 Max: 1

Detail - Optional



Purpose: To supply information on coordination of benefits


COB01 1138 Payer Responsibility Sequence Number Code O ID 1/1 Required

Description: Code identifying the insurance carrier's level of responsibility for a payment of a claim


Code Name

P Primary

S Secondary

T Tertiary

U Unknown

COB02 127 Reference Identification O AN 1/50 Situational



COB03 1143 Coordination of Benefits Code O ID 1/1 Required

Description: Code identifying whether there is a coordination of benefits


Code Name

1 Coordination of Benefits

5 Unknown

6 No Coordination of Benefits

COB04 1365 Service Type Code O ID 1/2 Situational

Description: Code identifying the classification of service


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.


65

REF Additional Coordination of

Benefits Identifiers

Pos: 4050 Max: 4

Detail - Optional








Code Name

60 Account Suffix Code

6P Group Number

SY Social Security Number

ZZ Mutually Defined







66

DTP Coordination of Benefits

Eligibility Dates

Pos: 4070 Max: 2

Detail - Optional








Code Name

344 Coordination of Benefits Begin

345 Coordination of Benefits End




Code Name






67

Loop Coordination of Benefits Related

Entity

Pos: 4100 Repeat: 3

Optional





4100 NM1 Coordination of Benefits Related Entity O 1 Situational

4300 N3 Coordination of Benefits Related Entity Address O 1 Situational

4400 N4 Coordination of Benefits Other Insurance

Company City, State, ZIP Code

O 1 Required

4500 PER Administrative Communications Contact O 1 Situational


68

NM1 Coordination of Benefits

Related Entity

Pos: 4100 Max: 1

Detail - Optional








Code Name

36 Employer

GW Group

IN Insurer




Code Name

2 Non-Person Entity

NM103 1035 Name Last or Organization Name X AN 1/60 Situational





Code Name


NI National Association of Insurance Commissioners (NAIC) Identification




ExternalCodeList

Name: 540









69

N3 Coordination of Benefits

Related Entity Address

Pos: 4300 Max: 1

Detail - Optional










70

N4 Coordination of Benefits Other

Insurance Company City,

State, ZIP Code

Pos: 4400 Max: 1

Detail - Optional









ExternalCodeList

Name: 22




for United States)

ExternalCodeList

Name: 932


ExternalCodeList

Name: 51




ExternalCodeList

Name: 5




ExternalCodeList

Name: 5








71

PER Administrative

Communications Contact

Pos: 4500 Max: 1

Detail - Optional








Code Name

CN General Contact




Code Name

TE Telephone







72

Loop Flexible Spending Account Pos: 5500 Repeat: 5

Optional



Purpose: To supply flexible spending account information


5500 FSA Flexible Spending Account O 1 Situational

5600 AMT Monetary Amount Information O 10 Situational

5700 DTP Date or Time or Period O 10 Situational

5750 REF Reference Information O >1 Situational


73

FSA Flexible Spending Account Pos: 5500 Max: 1

Detail - Optional



Purpose: To supply flexible spending account information


FSA01 875 Maintenance Type Code M ID 3/3 Required



FSA02 1202 Flexible Spending Account Selection Code O ID 1/1 Situational

Description: Code indicating selection of a type of Flexible Spending Account


FSA03 1203 Maintenance Reason Code O ID 2/3 Situational



FSA04 508 Account Number O AN 1/35 Situational


FSA05 594 Frequency Code O ID 1/1 Situational

Description: Code indicating frequency or type of activities or actions being reported


FSA06 1204 Plan Coverage Description O AN 1/50 Situational

Description: A description or number that identifies the plan or coverage

FSA07 1161 Product Option Code O ID 1/2 Situational

Description: Code indicating an option chosen for the product








Semantics: 1. FSA04 is the flexible spending account (FSA) policy number.

2. FSA05 specifies the frequency of contribution.


74

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 Pretax

2 Post-tax

3 Qualified4 Non-qualified

5 401K

6 Individual Retirement Account

7 Keogh

8 Simplified Employee Pension

9 Single Premium

A First to Die

B Last to Die

C Child Rider

D Discontinue One-Bill Submission

N Benefit Continuation

O One-Bill Submission

S Salary Continuation

10 Flexible Premium

11 Variable Premium

12 Fixed Premium

13 Registered under the Income Tax Act of Canada

14 Non-Registered under the Income Tax Act of Canada

15 Registered Spousal Case

28 Exclusive


75

29 Shopped

30 Lead Reinsurer

31 Facultative Excess

BA Bank Account

GA Government Allocation

NC One-Bill Submission Not Chosen

PD Payroll Deduction

FSA08 IS SITUATIONAL BUT NOT REQUIRED BY THIS GUIDE

FSA09 IS SITUATIONAL BUT NOT REQUIRED BY THIS GUIDE


76

AMT Monetary Amount Information Pos: 5600 Max: 10

Detail - Optional



Purpose: To indicate the total monetary amount


AMT01 522 Amount Qualifier Code M ID 1/3 Required

Description: Code to qualify amount


AMT02 782 Monetary Amount M R 1/18 Required

Description: Monetary amount

AMT03 478 Credit/Debit Flag Code O ID 1/1 Situational

Description: Code indicating whether amount is a credit or debit


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>”


77

DTP Date or Time or Period Pos: 5700 Max: 10

Detail - Optional














BCI Requirements:

DTP01 IS REQUIRED AND SHOULD CONTAIN "<390 - Payroll Begin &391 - Payroll

End>"




78

REF Reference Information Pos: 5750 Max: >1

Detail - Optional








REF02 127 Reference Identification X AN 1/50 Situational



REF03 352 Description X AN 1/80 Situational

Description: A free-form description to clarify the related data elements and their content

REF04 C040 Reference Identifier O Comp Situational

Description: To identify one or more reference numbers or identification numbers as specified by the

Reference Qualifier

REF04-01 128 Reference Identification Qualifier M ID 2/3 Required



REF04-02 127 Reference Identification M AN 1/50 Required



REF04-03 128 Reference Identification Qualifier X ID 2/3 Situational



REF04-04 127 Reference Identification X AN 1/50 Situational



REF04-05 128 Reference Identification Qualifier X ID 2/3 Situational



REF04-06 127 Reference Identification X AN 1/50 Situational






79

Loop Additional Reporting Categories Pos: 6880 Repeat: 1

Optional

Loop: LS Elements: N/A


Purpose: To indicate that the next segment begins a loop


6880 LS Additional Reporting Categories O 1 Situational

6881 Loop 2700 O >1 Situational

6885 LE Additional Reporting Categories Loop

Termination

O 1 Situational


80

LS Additional Reporting

Categories

Pos: 6880 Max: 1

Detail - Optional

Loop: LS Elements: 1


Purpose: To indicate that the next segment begins a loop


LS01 447 Loop Identifier Code M AN 1/4 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.


81

Loop Member Reporting Categories Pos: 6881 Repeat: >1

Optional





6881 LX Member Reporting Categories O 1 Situational

6882 Loop 2750 M 1 Situational


82

LX Member Reporting Categories Pos: 6881 Max: 1

Detail - Optional





LX01 554 Assigned Number M N0 1/6 Required

Description: Number assigned for differentiation within a transaction set


83

Loop Reporting Category Pos: 6882 Repeat: 1

Mandatory





6882 N1 Reporting Category M 1 Situational

6883 REF Reporting Category Reference M 16 Situational

6884 DTP Reporting Category Date O 1 Situational


84

N1 Reporting Category Pos: 6882 Max: 1

Detail - Mandatory








Code Name

75 Participant

N102 93 Name X AN 1/60 Required








85

REF Reporting Category Reference Pos: 6883 Max: 16

Detail - Mandatory








Code Name

00 Contracting District Number


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







86

DTP Reporting Category Date Pos: 6884 Max: 1

Detail - Optional








Code Name

007 Effective




Code Name


RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD





87

LE Additional Reporting

Categories Loop Termination

Pos: 6885 Max: 1

Detail - Optional

Loop: LS Elements: 1


Purpose: To indicate that the loop immediately preceding this segment is complete


LE01 447 Loop Identifier Code M AN 1/4 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.


88

SE Transaction Set Trailer Pos: 6900 Max: 1

Detail - Mandatory



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)


SE01 96 Number of Included Segments M N0 1/10 Required

Description: Total number of segments included in a transaction set including ST and SE segments

SE02 329 Transaction Set Control Number M 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>"


89

GE Functional Group Trailer Pos: Max: 1




Purpose: To indicate the end of a functional group and to provide control information


GE01 97 Number of Transaction Sets Included M N0 1/6 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 Group Control Number M 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>"


90

IEA Interchange Control Trailer Pos: Max: 1




Purpose: To define the end of an interchange of zero or more functional groups and interchange-related control segments


IEA01 I16 Number of Included Functional Groups M N0 1/5 Required

Description: A count of the number of functional groups included in an interchange

IEA02 I12 Interchange Control Number M N0 9/9 Required

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>"

834 Benefit Enrollment and Maintenance 5010...LS Loop Additional Reporting Categories ... 2/0200 The...

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