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

Example 7: Terminate Eligibility for a Subscriber

The eligibility for John Doe is being canceled because he terminated employment on 10/1/1996.

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.

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*024*08*A***TE~

Beginning of Table 2. Indicates that the subscriber (John Doe) is terminating all coverage.

REF*0F*123456789~

John's subscriber ID number.

REF*1L*123456001~

This is the group number assigned by the carrier.

DTP*357*D8*19961001~

The benefits under this plan are terminating 10/01/1996.

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

Subscriber's name.

SE*10*12345~

End of transaction set. 10 segments were sent and the control number in the ST segment is 12345.