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

Example 6: Cancel a dependent

John Doe is canceling coverage for his over-age dependent, James, to be effective 8/1/1996.

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*024*07*A~

Beginning of Table 2. Indicates that the dependent (James Doe) is terminating all coverages.

REF*0F*123456789~

John's subscriber ID number.

REF*1L*123456001~

This is the group number assigned by the carrier.

DTP*357*D8*19960801~

The benefits under this plan are terminating 8/01/1996.

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

Dependent's name and SSN.

DMG*D8*19770816*M~

This is James' date of birth and gender.

SE*12*12345~

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