ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X220
Example 03: Enroll an Employee in a Managed Care Product
William Smith is enrolling in the HMO product effective 6/1/1996. He has selected Dr. Bernard Brown as his primary care physician for the program. Mr. Smith is already Dr. Brown's patient. Dr. Brown's provider number is 143766.
Transmission Explanation
Table 1
ST*834*12345*005010X220A1~
Used to indicate the start of a transaction set and to specify a transaction set control number.
BGN*00*12456*19980520*1200****2~
This is an original transaction uniquely identified by the sender with reference #12456. The transaction was created on 5/20/1998 at 12:00 Noon.
N1*P5**FI*999888777~
Specifies the sponsor/sender's tax ID number.
N1*IN**FI*654456654~
Specifies the insurance company/receiver's tax ID number.
Table 2
INS*Y*18*021*20*A***FT~
Beginning of Table 2.Indicates that the subscriber (William Smith) is receiving benefits as an active fulltime employee.
REF*0F*202443307~
William's subscriber ID number.
REF*1L*123456001~
This is the group number assigned by the carrier.
DTP*356*D8*19960112~
William first became eligible for coverage on 1/12/96.
NM1*IL*1*SMITH*WILLIAM****34*202443307~
Subscriber's name and SSN.
PER*IP**HP*7172343334*WP*7172341240~
William's home phone number is (717)234-3334 and his work number is (717) 234-1240.
N3*1715 SOUTHWIND AVENUE~
This is William's street address.
N4*ANYTOWN*PA*171110000~
This is William's city, state zip code and country.
DMG*D8*19700614*M~
This is William's date of birth and gender.
HD*021**HMO~
William is enrolling in a HMO benefit.
DTP*348*D8*19960601~
The benefits under this plan begin 6/01/1996.
LX*01~
This starts the provider information.
NM1*P3*1*BROWN*BERNARD**DR**SV*143766*25~
This gives the provider name, ID number and indicates William is a previous patient of Dr. Brown.
SE*18*12345~
End of transaction set. 18 segments were sent and the control number in the ST segment is 12345.