ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X220
Example 01: Enroll an Employee in Multiple Health Care Insurance Products
John Doe is enrolling in three health care products - health, dental, and vision. He also has Coordination of Benefits (COB) with another insurance company.
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 (John Doe) is adding coverage as an active employee.
REF*0F*123456789~
John's subscriber ID number.
REF*1L*123456001~
This is the group number assigned by the carrier.
DTP*356*D8*19960523~
The eligibility date for this transaction is 5/23/1996.
NM1*IL*1*DOE*JOHN*P***34*123456789~
Subscriber's name.
PER*IP**HP*7172343334*WP*7172341240~
John's home phone number is (717)234-3334 and his work number is (717) 234-1240.
N3*100 MARKET ST*APT 3G~
This is John's street address.
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
This is John's city, state zip code and county.
DMG*D8*19400816*M~
This is John's date of birth and gender.
HD*021**HLT~
John is enrolling in a health benefit.
DTP*348*D8*19960601~
The benefits under this plan begin 6/01/1996.
COB*P*890111*5~
This lets the carrier know that John has COB with another company.
HD*021**DEN~
John is enrolling in the Dental benefit.
DTP*348*D8*19960601~
The benefits under this plan begin 6/01/1996.
HD*021**VIS~
John is enrolling in the Vision benefit.
DTP*348*D8*19960601~
The benefits under this plan begin 6/01/1996.
SE*21*12345~
End of transaction set. 21 segments were sent and the control number in the ST segment is 12345.