Section title: X12 EDI Examples
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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.

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.