Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X220

Example 1: 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.