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

Example 2: Add a Dependent (Full-time Student) to an Existing Enrollment

James E. Doe, the son of John Doe, is being enrolled under John Doe's medical coverage. James is enrolled at Penn State and expects to graduate on 5/15/1998. His Social Security Number is 103229876. The enrollment for the subscriber, John Doe, had to be submitted before his dependents can be enrolled.

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.

REF*38*ABCD012354~

Master policy number (group ID).

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*N*19*021*28*A****F~

Beginning of Table 2. Indicates that the dependent (James Doe) is adding coverage as a full time student.

REF*0F*123456789~

John's subscriber ID number.

REF*1L*123456001~

This is the group number assigned by the carrier.

DTP*351*D8*19980515~

The expected graduation date from Penn State is 5/15/1998.

NM1*IL*1*DOE*JAMES*E***34*103229876~

Dependents name and ssn.

DMG*D8*19770816*M~

This is James date of birth and gender.

NM1*M8*2*PENN STATE UNIVERSITY~

This is the school that James attends.

HD*021**HLT~

James is enrolling in a health benefit.

DTP*348*D8*19960601~

The benefits under this plan begin 6/01/1996.

SE*15*12345~

End of transaction set. 15 segments were sent and the control number in the ST segment is 12345.