ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X220
Example 3: 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.
Used to indicate the start of a transaction set and to specify a transaction set control number.
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.
Specifies the sponsor/sender's tax ID number.
Specifies the insurance company/receiver's tax ID number.
Beginning of Table 2.Indicates that the subscriber (William Smith) is receiving benefits as an active fulltime employee.
William's subscriber ID number.
This is the group number assigned by the carrier.
William first became eligible for coverage on 1/12/96.
Subscriber's name and SSN.
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.
This is William's city, state zip code and country.
This is William's date of birth and gender.
William is enrolling in a HMO benefit.
The benefits under this plan begin 6/01/1996.
This starts the provider information.
This gives the provider name, ID number and indicates William is a previous patient of Dr. Brown.
End of transaction set. 18 segments were sent and the control number in the ST segment is 12345.