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

Example 4: Add Subscriber Coverage

William Smith is adding dental coverage as a benefit, which will be effective on 7/1/2002.

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*20020601*1200****2~

This is an original transaction uniquely identified by the sender with reference #12456. The transaction was created on 6/1/2002 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*Y*18*001*22*A***FT~

Beginning of Table 2. Indicates that the subscriber (William Smith) is updating coverage as an active employee.

REF*0F*202443307~

William's subscriber ID number.

REF*1L*123456001~

This is the group number assigned by the carrier.

NM1*IL*1*SMITH*WILLIAM****ZZ*2024433307~

Subscriber's name.

HD*021**DEN~

William is enrolling in the Dental benefit.

DTP*348*D8*20020701~

The benefits under this plan begin 7/1/2002.

SE*12*12345~

End of transaction set. 12 segments were sent and the control number in the ST segment is 12345.

NOTE

In the previous example, to remove coverage do the following: change the maintenance type code (HD01) from 021 (addition) to 024 (cancellation/termination), and change the date/time qualifier (DTP01) from 348 (benefit begin) to 349 (benefit end).