HIPAA 834 Companion Guide

HIPAA 834 Companion Guide

Benefit and Enrollment Maintenance - 834

HIPAA 834 Companion Guide

Version 5010X220A1

ASCX12

5/29/2014

COPYRIGHT© Willamette Dental Group,2014. AllRights Reserved.

Table of Contents(boldrequired)

834Benefit Enrollment and Maintenance ...... 3-5

ISAInterchange Control Header ...... 6-8

GSFunctional Group Header ...... 8-9

STTransaction Set Header ...... 10

BGNBeginning Segment ...... 10-11

REF Transaction Set Policy Number ...... 12

DTPFile Effective Date ...... 11-13
QTYTransaction Set Control Totals ...... 13

1000ALoop Sponsor Name ...... 14

N1Sponsor Name ...... 14

1000BLoop Payer ...... 15

N1Payer ...... 15

1000CLoop TPA/Broker Name ...... 16

N1TPA/Broker Name ...... 16

2000Loop Member Level Detail...... 17

INSMember Level Detail ...... 17-20

REFSubscriber Identifier ...... 21

REFMember Policy Number ...... 22

REF Member Supplemental Identifier ...... 23

DTP Member Level Dates ...... 24

2100ALoop Member Name ...... 25

NM1 Member Name ...... 25-26

PERMember Communications Numbers ...... 26-27

N3Member Residence Street Address ...... 27

N4Member City, State, ZIP Code ...... 28

DMGMember Demographics ...... 29-30

EC Employment Class ...... 31
ICMMember Income……………………………………………………………………………………………………………….32
AMTMember Policy Amounts……………………………………………………………………………………………………..33
HLHMember Health Information………………………………………………………………………………………………….33-34
LUIMember Language……………………………………………………………………………………………………………34
2100BLoop Incorrect Member Name……………………………………………………………………………………………….35
NM1Incorrect Member Name………………………………………………………………………………………………………35-36
DMGIncorrect Member Demographics……………………………………………………………………………………………36-37
2100CMember Mailing Address……………………………………………………………………………………………………..38
NM1Member Mailing Address……………………………………………………………………………………………………..38
N3Member Mail Street Address…………………………………………………………………………………………………39
N4Member Mail City, State, Zip Code………………………………………………………………………………………….39
2100DLoop Member Employer………………………………………………………………………………………………………40
NM1Member Employer……………………………………………………………………………………………………………..40-41
PERMember Employer Communications Numbers……………………………………………………………………………..41-42
N3Member Employer Street Address…………………………………………………………………………………………..42
N4Member Employer City, State, Zip Code……………………………………………………………………………………42-43
2100ELoop Member School………………………………………………………………………………………………………….43
NM1Member School…………………………………………………………………………………………………………………43
PERMember School Communications Numbers………………………………………………………………………………..44
N3Member School Street Address……………………………………………………………………………………………..45
N4Member School City, State, Zip Code………………………………………………………………………………………45
2100FLoop Custodial Parent………………………………………………………………………………………………………..46
NM1Custodial Parent………………………………………………………………………………………………………………46
PERCustodial Parent Communications Numbers………………………………………………………………………………47
N3Custodial Parent Street Address…………………………………………………………………………………………….48
N4Custodial Parent City, State, Zip Code……………………………………………………………………………………..48
2100GLoop Responsible Person……………………………………………………………………………………………………49
NM1Responsible Person…………………………………………………………………………………………………………..49-50
PERResponsible Person Communications Numbers…………………………………………………………………………..50-51
N3Responsible Person Street Address…………………………………………………………………………………………51
N4Responsible Person City, State, Zip Code…………………………………………………………………………………51-52
2100HLoop Drop Off Location……………………………………………………………………………………………………….52
NM1Drop Off Location………………………………………………………………………………………………………………52
N3Drop Off Location Street Address……………………………………………………………………………………………53
N4Drop Off Location City, State, Zip Code……………………………………………………………………………………..53
2200Loop Disability Information……………………………………………………………………………………………………54
DSBDisability Information…………………………………………………………………………………………………………..54
DTPDisability Eligibility Dates……………………………………………………………………………………………………54-55

2300Loop Health Coverage ...... 55

HDHealth Coverage ...... 55-56

DTPHealth Coverage Dates ...... 57

AMT Health Coverage Policy ...... 57-58

REF Health Coverage Policy Number ...... 58

REF Prior Coverage Months ...... 59
IDCIdentification Card……………………………………………………………………………………………………………59-60

2310 Loop Provider Information ...... 60

LX Provider Information...... 60

NM1 Provider Name ...... 60-61

N3 Provider Address ...... 62

N4 Provider City, State, ZIP Code ...... 62

PER Provider Communications Numbers ...... 63

PLA Provider Change Reason ...... 64

2320 Loop Coordination of Benefits ...... 65

COB Coordination of Benefits...... 65

REF Additional Coordination of Benefits Identifiers ...... 66

DTP Coordination of Benefits Eligibility Dates ...... 66-67

2330 Loop Coordination of Benefits Related Entity ...... 67

NM1 Coordination of Benefits Related Entity ...... 67

N3 Coordination of Benefits Related Entity Address ...... 68

N4 Coordination of Benefits Other Insurance Company City, State, ZIP Code ...... 68

PER Administrative Communications Contact ...... 69

LS Additional Reporting Categories ...... 69

2700 Loop Member Reporting Categories ...... 70
LX Member Reporting Categories ...... 70

2750 Loop Reporting Category ...... 70

N1 Reporting Category ...... 70

REF Reporting Category Reference ...... 71

DTP Reporting Category Date ...... 71-72

LE Additional Reporting Categories Loop Termination ...... 72

SETransaction Set Trailer ...... 73

GEFunctional Group Trailer ...... 73

IEAInterchange Control Trailer ...... 74

*after each segment will be the WDG requirements for that segment high-lighted in yellow

834 Benefit Enrollment and Maintenance Companion Guide
HIPAA -V5010X220A1 - 834

Purpose:This X12TransactionSetcontainsthe formatandestablishes the data contentsofthe BenefitEnrollmentand Maintenance Transaction Set(834)for usewithin the context ofanElectronic Data Interchange (EDI)environment.This transactionsetcanbe usedtoestablishcommunicationbetweenthe sponsorofthe insurance productandthe payer. Such transaction(s) mayormaynottake place througha third partyadministrator(TPA). Forthe purposeofthis standard,the sponsor is the partyorentitythatultimatelypays forthe coverage, benefit or product.Asponsor can be an employer, union,government agency,association,orinsuranceagency.The payerrefers toanentitythat pays claims,administers the insurance productor benefit, orboth.Apayer can beaninsurance company, healthmaintenance organization(HMO),preferred providerorganization (PPO),governmentagency(Medicare, Medicaid,Champus,etc.), oranentitythatmaybe contracted byone oftheseformer groups.Forthe purposeofthe834transactionset,a third partyadministrator(TPA)can be contracted bya sponsorto handle data gatheringfromthose covered bythe sponsorifthe sponsordoesnotelecttoperformthis functionitself.

Not Defined:
PosIdSegment NameUsageMaxUseNotesLoop Repeat
ISAInterchange Control Header Required 1
GSFunctional Group Header Required 1

Header:
PosIdSegment NameUsageMaxUseNotesLoop Repeat
0100STTransaction Set Header Required 1
0200 BGNBeginning Statement Required 1
0300 REFTransaction Set Policy Number Situational 1
0400DTPFile Effective DateSituational >1
0600QTYTransaction Set Control Totals Situational 3
LOOP– 1000A SPONSOR NAME 1
0700N1Sponsor NameRequired 1N1
LOOP– 1000B PAYER 1
0700N1PayerRequired 1N2
LOOP– 1000C TPA/BROKER NAME 2
0700N1TPA/Broker NameSituational 1N3
Detail:
PosIdSegment NameUsageMaxUseNotesLoop Repeat
LOOP – 2000 MEMBER LEVEL DETAIL >1
0100INSMember Level DetailRequired 1N4
0200REFSubscriber IdentifierRequired 1N5
0200REFMember Policy NumberRequired 1N6
0200REFMember Supplemental IdentifierSituational 13
0250DTPMember Level DatesSituational 24
LOOP – 2100A MEMBER NAME 1
0300NM1Member NameRequired 1

PosIdSegment NameUsageMaxUseNotesLoop Repeat
0400PERMember Communication NumbersSituational 1
0500N3Member Residence Street AddressSituational 1
0600N4Member City, State, ZIP CodeRequired 1N7
0800DMGMember DemographicsRequired 1
1000ECEmployment ClassSituational >1
1100ICMMember IncomeSituational 1
1200AMTMember Policy AmountsSituational 7
1300HLHMember Health InformationSituational 1
1500LUIMember LanguageSituational >1
LOOP – 2100B INCORRECT MEMBER NAME 1
0300NM1Incorrect Member NameSituational 1
0800DMGIncorrect Member DemographicsSituational 1
LOOP – 2100C MEMBER MAILING ADDRESSN8 1
0300NM1Member Mailing AddressSituational 1N8
0500N3Member Mail Street AddressRequired 1N8
0600N4Member Mail City, State, ZIP CodeRequired 1N8
LOOP – 2100D MEMBER EMPLOYER 3
0300NM1Member EmployerSituational 1
0400PERMember Employer Communications NumbersSituational 1
0500N3Member Employer Street AddressSituational 1
0600N4Member Employer City, State, ZIP CodeRequired 1N9
LOOP – 2100E MEMBER SCHOOL 3
0300NM1Member SchoolSituational 1
0400PERMember School Communications NumbersSituational 1
0500N3Member School Street AddressSituational 1
0600N4Member School City, State, ZIP CodeRequired 1N10
LOOP – 2100F CUSTODIAL PARENT 1
0300NM1Custodial ParentSituational 1
0400PERCustodial Parent Communications NumbersSituational 1
0500N3Custodial Parent Street AddressSituational 1
0600N4Custodial Parent City, State, ZIP CodeRequired 1N11
LOOP – 2100G RESPONSIBLE PERSON 13
0300NM1Responsible PersonSituational 1
0400PERResponsible Person Communications NumbersSituational 1
0500N3Responsible Person Street AddressSituational 1
0600N4Responsible Person City, State, ZIP CodeRequired 1N12
LOOP – 2100H DROP OFF LOCATION 1
0300NM1Drop Off LocationSituational 1
0500N3Drop Off Location Street AddressSituational 1
0600N4Drop Off Location City, State, ZIP CodeRequired 1N13
LOOP – 2200 DISABILITY INFORMATION >1
2000DSBDisability InformationSituational 1
2100DTPDisability Eligibility DatesSituational 2
LOOP – 2300 HEALTH COVERAGE 99
2600HDHealth CoverageRequired 1
2700DTPHealth Coverage DatesRequired 6
2800AMTHealth Coverage PolicySituational 9
2900REFHealth Coverage Policy NumberRequired 14N14
2900REFPrior Coverage MonthsSituational 1
3000IDCIdentification CardSituational 3

PosIdSegment NameUsageMaxUseNotesLoop Repeat
LOOP – 2310 PROVIDER INFORMATION 30
3100LXProvider InformationSituational 1
3200NM1Provider NameRequired 1N15
3500N3Provider AddressSituational 2
3600N4Provider City, State, ZIP CodeRequired 1N16
3700PERProvider Communications NumbersSituational 2
3950PLAProvider Change ReasonSituational 1
LOOP – 2320 COORDINATION OF BENEFITS 5
4000COBCoordination of BenefitsSituational 1
4050REFAdditional Coordination of Benefits IdentifiersSituational 4
4070DTPCoordination of Benefits Eligibility DatesSituational 2
LOOP – 2330 COORDINATION OF BENEFITS 3
RELATED ENTITY
4100NM1Coordination of Benefits Related EntitySituational 1
4300N3Coordination of Benefits Related Entity AddressSituational 1
4400N4COB Other Insurance CO City, State, ZIP CodeRequired 1N17
4500PERAdministrative Communications ContactSituational 1
6880LSAdditional Reporting CategoriesSituational 1
LOOP – 2710 MEMBER REPORTING CATEGORIES >1
6881LXMember Reporting CategoriesSituational 1
LOOP – 2750 REPORTING CATEGORY 1
6882N1Reporting CategorySituational 1
6883REFReporting Category ReferenceSituational 16
6884DTPReporting Category DateSituational 1
6885LEAdditional Reporting Categories Loop TerminateSituational 1
6900SETransaction Set TrailerRequired 1

Not Defined:
PosIdSegment NameUsageMaxUseNotesLoop Repeat
GEFunctional Group TrailerRequired 1
IEAInterchange Control TrailerRequired 1
Notes:

  1. At least one iteration of loop 1000 is required to identify the sender.
  2. At least one iteration of loop 1000 is required to identify the receiver.
  3. At least one iteration of loop 1000 is required to identify the sender, if TPA is involved.
  4. A Subscriber is a person who elects 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, domestic partner, etc., and is therefore entitled to benefits. A Dependent cannot exist in the file without a corresponding Subscriber record.
  5. This REF segment is required to link the dependent(s) to the subscriber.
  6. This REF segment is required when there is a WDG assigned Group ID#.
  7. N4 is required when N3 is used.
  8. Required when the member mailing address is different from theresidence address sent in loop 2100A or when the dependent’s address isdifferent from the subscriber. If loop 2100C is used, then N3 and N4 are required.
  9. N4 is required when N3 is used if Loop 2100D is used
  10. N4 is required when N3 is used if Loop 2100E is used
  11. N4 is required when N3 is used if Loop 2100F is used
  12. N4 is required when N3 is used if Loop 2100G is used
  13. N4 is required when N3 is used if Loop 2100H is used
  14. This REF segment is required to pass the WDG assigned Plan ID#
  15. NM1 is required if Loop 2310 is used
  16. N4 is required when N3 is used if Loop 2310 is used
  17. N4 is required when N3 is used if Loop 2330 is used

ISA - INTERCHANGE CONTROL HEADER

X12 Segment Name: Interchange Control Header

X12 Purpose: To start and identify an interchange of zero or more functional groups andInterchange-related control segments

Usage: Required

TR3 Example (…. used to indicate spaces):
ISA*00*……….*00*……….*30*999999999……*30*931226036……*130301*1015*^*00501*000000905*0*P*>~

Element Detail:

RefNameTypeMin/MaxUsage

ISA01Authorization Information QualifierID2/2Required

Code identifying the type of information in the Authorization Information

CodeDefinition

00No Authorization Information Present (No Meaningful Information in I02)

03Additional Data Identification

ISA02Authorization InformationAN10/10Required
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)

ISA03Security Information QualifierID2/2Required
Code identifying the type of information in the Security Information

CodeDefinition
00No Security Information Present (No Meaningful Information in I04)
01Password

ISA04Security InformationAN2/2Required
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)

ISA05Interchange ID QualifierID2/2Required
Code indicating the system/method of code structure used to designate the sender or receiver ID
element being qualified

This ID qualifies the Sender in ISA06.
CodeDefinition
01Duns (Dun & Bradstreet)
14Duns Plus Suffix
20Health Industry Number (HIN)
27Carrier ID Number as assigned by Health Care Financing Administration
29Medicare Provider & Supplier ID Number assigned HCFA
30U.S. Federal Tax ID Number
33National Association of Insurance Commissioners Company Code
ZZMutually Defined

ISA06Interchange Sender IDAN15/15Required
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

RefNameTypeMin/MaxUsage

ISA07 Interchange ID QualifierID2/2Required
Code indicating the system/method of code structure used to designate the sender or receiver ID
element being qualified.

This ID qualifies the Receiver in ISA08.
See codes listed above for ISA05.

ISA08Interchange Receiver IDAN15/15Required
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.

ISA09Interchange DateDT6/6Required
Date of the interchange

The date format is YYMMDD.

ISA10Interchange TimeTM4/4Required
Time of the interchange

The time format is HHMM.

ISA11 Repetition Separator1/1Required
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.

ISA12Interchange Control Version NumberID5/5Required
Code specifying the version number of the interchange control segments

CodeDefinition
00501Standards Approved for Publication by ASC X12 Procedures Review
Board through October 2003

ISA13Interchange Control NumberNO9/9Required
A control number assigned by the interchange sender

The Interchange Control Number, ISA13, must be identical to the associated Interchange
Trailer IEA02.

Must be a positive unsigned number and must be identical to the value in IEA02.

ISA14Acknowledgment RequestedID1/1Required
Code indicating sender’s request for an interchange acknowledgment

CodeDefinition
0No Interchange Acknowledgment Requested
1Interchange Acknowledgment Requested (TA1)

ISA15 Interchange Usage IndicatorID1/1Required
Code indicating whether data enclosed by this interchange envelope is test or production

CodeDefinition
PProduction Data
TTest Data

RefNameTypeMin/MaxUsage

ISA16 Component Element Separator1/1Required
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.

WDG Requirements:
ISA01 is required and should contain “00”
ISA02 is required and should contain “<BLANK>”
ISA03 is required and should contain “00”
ISA04 is required and should contain “<BLANK>”
ISA05 is required and should contain “30”
ISA06 is required and should contain “<The Federal Tax ID of Sender>”
ISA07 is required and should contain “30”
ISA08 is required and should contain “931226036”
ISA09 is required and should contain “<YYMMDD>”
ISA10 is required and should contain “<HHMM>”
ISA11 is required and should contain “^”
ISA12 is required and should contain “00501”
ISA13 is required and should contain “<Unique Number>”
ISA14 is required and should contain “0”
ISA15 is required and should contain “<P or T>”
ISA16 is required and should contain “”
Element Separator = *
Segment Terminator = ~

GS – Functional Group Header

X12 Segment Name: Functional Group Header

X12 Purpose: To indicate the beginning of a functional group and to provide control information

Usage: Required
TR3 Example:GS*BE*999999999*931226036*20130301*1015*1*X*005010X220A1~

Element Detail:

RefNameTypeMin/MaxUsage

GS01Functional Identifier CodeID2/2Required
Code identifying a group of application related transaction sets

CodeDefinition
BEBenefit Enrollment and Maintenance (834)

GS02Application Sender’s CodeAN2/15Required
Code identifying party sending transmission; codes agreed to by trading partners

GS03Application Receiver’s CodeAN2/15Required
Code identifying party receiving transmission; codes agreed to by trading partners

RefNameTypeMin/MaxUsage

GS04DateDT8/8Required
Date expressed as CCYYMMDD

GS05TimeTM4/8Required
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)
The recommended format is HHMM.

GS06 Group Control NumberNO1/9Required
Assigned number originated and maintained by the sender

Semantic: The data interchange control number GS06 in this header must be identical to the
same data element in the associated functional group trailer, GE02.

GS07Responsible Agency CodeAN1/2Required
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CodeDefinition
XAccredited Standards Committee X12

GS08 Version/Release/Industry Identifier CodeAN1/12Required
Code indicating the version, release, subrelease, & industry identifier of the EDI standard being used

CodeDefinition
005010X220A1Standards Approved for Publication by ASC X12 Procedures
Review Board through October 2003

WDG Requirements:
GS01 is required and should contain “BE”
GS02 is required and should contain “Fed Tax ID of Sender”
GS03 is required and should contain “931226036”
GS04 is required and should contain “<CCYYMMDD>”
GS05 is required and should contain “<HHMM>”
GS06 is required and should contain “Unique Number”
GS07 is required and should contain “X”
GS08 is required and should contain “005010X220A1”

ST – Transaction Set Header

X12 Segment Name: Transaction Set Header

X12 Purpose: To indicate the start of a transaction set and to assign a control number

Usage: Required
TR3 Example:ST*834*0001*005010X220A1~

Element Detail:

RefNameTypeMin/MaxUsage

ST01Transaction Set Identifier CodeID3/3Required
Code uniquely identifying a Transaction Set

CodeDefinition
834Benefit Enrollment Maintenance

ST02Transaction Set Control NumberAN4/9Required
Identifying control number that must be unique within the transaction set functional group assigned
by the originator for a transaction set

The Transaction Set Control Number in ST03 and SE02 must be identical

ST03Implementation Convention ReferenceAN1/35Required
Reference assigned to identify Implementation Convention
This field contains the same value as GS08.

WDG Requirements:
ST01 is required and should contain “834”
ST02 is required and should contain “Unique Number”
ST03 is required and should contain “005010X220A1”

BGN – Beginning Statement

X12 Segment Name: Beginning Statement

X12 Purpose: To indicate the beginning of a transaction set

Usage: Required
TR3 Example:BGN*00*0001*20130301*1015****RX~

Element Detail:

RefNameTypeMin/MaxUsage

BGN01Transaction Set Purpose CodeID2/2Required
Code identifying purpose of transaction set

CodeDefinition
00Original
15Re-Submission
22Information Copy

RefNameTypeMin/MaxUsage

BGN02Reference IdentificationAN1/50Required
Reference information as defined for a particular Transaction Set or as specified by the Reference
Identification Qualifier

BGN02 is the Transaction Set Reference Number assigned by the sender’s application

BGN03DateDT8/8Required
Date expressed as CCYYMMDD. Transaction Set Creation Date.

BGN04TimeTM4/8Required
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). Transaction Set Creation Time.

BGN05Time CodeID2/2Situational
Code identifying the time zone.

Situational Rule: Required when the sender and receiver are not in the same time zone.
All valid standard codes are used. (Total Codes: 51)

BGN06Reference IdentificationAN1/50Situational
Reference information as defined for a particular Transaction Set or as specified by the Reference
Identification Qualifier.

Situational Rule: Required when there is a previously sent transaction to cross-reference.

BGN07Transaction Type CodeID2/2Not Used

BGN08Action CodeID1/2Required
Code Indication type of action

CodeDefinition
2Change (Update)
4Verify
RXReplace

BGN09Security Level CodeID2/2Not Used

WDG Requirements:
BGN01 is required and should contain “00”
BGN02 is required and should contain “Fed Tax ID of Sender”
BGN03 is required and should contain “<CCYYMMDD>”
BGN04 is required and should contain “<HHMM>”
BGN05 is situational and should contain “<PT>”
BGN06 is situational and should not be used since BGN01 will always be 00(Original)
BGN07is not used
BGN08 is required and should contain “<2 or RX>”Note: 2 for “change” files and RX for “full file” replacement files. “4” will notupdate anything in the WDGsystem as it is only meant for audit/compare reporting

BGN09 is not used

REF – Transaction Set Policy Number

X12 Segment Name: Reference Information

X12 Purpose: To specify identifying information

Usage: Situational
TR3 Example:REF*38*12345~

Element Detail:

RefNameTypeMin/MaxUsage

REF01Reference Identification QualifierID2/3Required
Code qualifying the Reference Identification
CodeDefinition
38Master Policy Number

REF02Reference IdentificationAN1/50Required
Reference Information as defined for a particular Transaction Set or as specified by the Reference
Identification Qualifier. The definition of the Master Policy Number is determined by the issuer
of the policy, the Payer/Plan Administrator.

WDG Requirements:
DO NOT USE this segment. The value of REF02 will conflict with the Group ID information being passed
in the 2000 loop REF segment.

DTP – File Effective Date

X12 Segment Name: Date or Time or Period

X12 Purpose: To specify any or all of a date, a time, or a time period

Usage: Situational
TR3 Example:DTP*007*D8*20130301~

Element Detail:

RefNameTypeMin/MaxUsage

DTP01Date/Time QualifierID3/3Required
Code specifying type of date or time, or both.

CodeDefinition
007Effective
090Report Start
091Report End
303Maintenance Effective
382Enrollment
388Payment Commencement

DTP02Date Time Period Format QualifierID2/3Required
Code indicating the date or time format that will appear in DTP03

CodeDefinition
D8Date Expressed in Format CCYYMMDD

RefNameTypeMin/MaxUsage

DTP03Date Time PeriodAN1/35Required
Expression of a date, a time, or range of dates, times or dates and times

WDG Requirements:
DTP01 is required and should contain “007”
DTP02 is required and should contain “D8”
DTP03 is required and should contain “CCYYMMDD”

QTY – Transaction Set Control Totals

X12 Segment Name: Quantity Information

X12 Purpose: To specify quantity information

Usage: Situational
TR3 Example:QTY*TO*10000~

Element Detail:

RefNameTypeMin/MaxUsage

QTY01Quantity QualifierID2/2Required
Code specifying the type of quantity

CodeDefinition
DTDependent Total
ETEmployee Total
TOTotal

QTY02QuantityR1/15Required
Numeric value of quantity

QTY03Composite Unit of MeasureNot Used

QTY04Free-form InformationAN1/30Not Used

WDG Requirements:

Segment not required, but if used follow guide above (no WDG requirements)

Loop 1000A – Sponsor Name

N1 – SPONSOR NAME

X12 Segment Name: Party Identification

X12 Purpose: To identify a party by type of organization, name, and code

Usage: Required
TR3 Example:N1*P5*ABC Company*FI*12356799~

Element Detail:

RefNameTypeMin/MaxUsage

N101Entity Identifier CodeID2/3Required

Code identifying an organizational entity, a physical location,

property or an individual

CodeDefinition

P5Plan Sponsor

N102NameAN1/60Situational

Free-form name

N103Identification Code QualifierID1/2Required Code designating the system/method of code structure used for

Identification Code (67)

CodeDefinition

24Employer’s Identification Number

94Code assigned by the organization that is the ultimate

Destination of the transaction set

FIFederal Taxpayer’s Identification Number

N104Identification CodeAN2/80Required

Code identifying a party or other code

N105Entity Relationship CodeID2/2Not Used

N106 Entity Identifier CodeID2/3Not Used

WDG Requirements:
N101 is required and should contain “P5”

N102 is situational and should contain <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

Loop 1000B – Payer

N1 - PAYER

X12 Segment Name: Party Identification

X12 Purpose: To identify a party by type of organization, name, and code

Usage: Required
TR3 Example:N1*IN*Willamette Dental Group*FI*931226036~

Element Detail:

RefNameTypeMin/MaxUsage

N101Entity Identifier CodeID2/3Required