ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X307
Example 02: SHOP enrollment in a Qualified Health Plan through a Health Insurance Exchange
ABC Employer is presenting to a Qualified Health Plan (QHP) issuer through a Health Insurance Exchange (HIX) for the first time. John Doe is the employee and Jane Doe is his spouse/dependent. XYZ Employer is also presenting to the same QHP issuer for the first time. John Smith is the employee and Jane Smith is his spouse/dependent. Meanwhile, DEF Employer is already known to the QHP and is adding Jane Buck as a new enrollee. The Exchange has processed the eligibility for enrollment and is sending the enrollment to the QHP Issuer.
X12 Syntax
Table 1
ST*834*0001*005010X307~
BGN*00*12456*20131020*1200****2~
REF*38*573~
DTP*007*D8*20140101~
QTY*TO*5~
QTY*DT*2~
QTY*ET*3~
N1*41*EXCHANGE*46*999888778~
N1*40*RECEIVER*46*999888777~
N1*IN*ISSUER*FI*654456654~
The Employer Group enrollment information for ABC Employer is reported in the following group of segments.
N1*62*ABC EMPLOYER*24*123456789~
N3*P.O. Box 1234~
N4*KANSAS CITY*MO*64108~
PER*AJ*Enrollee ABC Employer Communications Contact*TE*8001234567~
PER*AL*Alternate Enrollee ABC Employer Communications Contact*TE*8001234567~
ACT*1~
REF*18*12565496~
REF*QQ*43~
REF*IJ*7349~
REF*DU*YES~
N3*P.O. Box 4321~
N4*KANSAS CITY*MO*64108~
PER*BI*Alternate Enrollee ABC Employer Billing Contact*TE*8001234567~
DTP*AB4*UN*30~
AMT*JN*100~
ACT*2~
N3*123 ANY STREET~
N4*KANSAS CITY*MO*64108~
PER*1I**TE*8001234567~
The Employer Group enrollment information for XYZ Employer is reported in the following group of segments.
N1*62*XYZ EMPLOYER*24*987654321~
N3*P.O. Box 9876~
N4*SOMEWHERE ELSE*IL*60616~
PER*AJ*Enrollee XYZ Employer Communications Contact*TE*8007654321~
PER*AL*Alternate Enrollee XYZ Employer Communications Contact*TE*8007654321~
ACT*1~
REF*18*7065983~
REF*QQ*21~
REF*IJ*7456~
REF*DU*YES~
DTP*AB4*UN*15~
AMT*93*.6~
Table 2
Enrollment information for John Doe employed by ABC Employer is reported in the following group of segments.
INS*Y*18*021*20*A***FT~
REF*WH*123456789~
REF*POL*123456~
REF*18*7065983~
DTP*356*D8*20140101~
NM1*IL*1*DOE*JOHN*P***34*999888777~
PER*IP**TE*3125555555*EM*DOEJ@EMAIL.COM~
N3*123 ANY AVE~
N4*CHICAGO*IL*60616**CY*COOK~
DMG*D8*19630930*M**C~
HLH*T~
HI*ZZ:3:D8:20140101:100~
For the purposes of this example, the values representing the CMS/CCIIO Enrollment Amounts Code Set reported in the second component of the composite are as follows:
3 = Total Premium Amount
NM1*P5*2*ABC EMPLOYER*****24*123456789~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
DTP*300*D8*20131019~
LS*2700~
LX*1~
N1*AG*MONEY TALKS AGENCY*FI*123356799~
REF*0B*123456*PA~
DTP*007*D8*20130915~
LE*2700~
Enrollment information for Jane Doe, spouse of John Doe employed by ABC Employer, is reported in the following group of segments.
INS*N*01*021*20*A***AC~
REF*6O*456789123~
REF*18*7065983~
REF*WH*123456789~
REF*POL*123456~
DTP*356*D8*20140101~
NM1*IL*1*DOE*JANE*R***34*888777999~
PER*IP**TE*3125555555*EM*DOEJ@EMAIL.COM~
N3*123 ANY AVE~
N4*CHICAGO*IL*60616**CY*COOK~
DMG*D8*19630910*F**I~
HI*ZZ:3:D8:20140101:100~
For the purposes of this example, the values representing the CMS/CCIIO Enrollment Amounts Code Set reported in the second component of the composite are as follows:
3 = Total Premium Amount
NM1*P5*2*ABC EMPLOYER*****24*123456789~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
LS*2700~
LX*1~
N1*AG*MONEY TALKS AGENCY*FI*123356799~
REF*0B*123456*PA~
DTP*007*D8*20130915~
LE*2700~
Enrollment information for John Smith employed by XYZ Employer is reported in the following group of segments.
INS*Y*18*021*20*A***FT~
REF*WH*987654321~
REF*POL*654321~
REF*18*12565496~
DTP*356*D8*20140101~
NM1*IL*1*SMITH*JOHN*P***34*111224321~
PER*IP**TE*2135555555*EM*SMITHJ@EMAIL.COM~
N3*123 ANY AVE~
N4*ROSWELL*NM*50313**CY*CHAVES~
DMG*D8*19720930*M**C~
HLH*T~
HI*ZZ:3:D8:20140101:150~
For the purposes of this example, the values representing the CMS/CCIIO Enrollment Amounts Code Set reported in the second component of the composite are as follows:
3 = Total Premium Amount
NM1*P5*2*XYZ EMPLOYER*****24*987654321~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
DTP*300*D8*20131019~
LS*2700~
LX*1~
N1*AG*MONEY TALKS AGENCY*FI*123356799~
REF*0B*123456*PA~
DTP*007*D8*20130915~
LE*2700~
Enrollment information for Jane Smith, spouse of John Smith employed by XYZ Employer, is reported in the following group of segments.
INS*N*01*021*20*A***AC~
REF*6O*456789123~
REF*18*12565496~
REF*WH*987654321~
REF*POL*654321~
DTP*356*D8*30240101~
NM1*IL*1*SMITH*JANE*R***34*888777999~
PER*IP**TE*2135555555*EM*SMITHJ@EMAIL.COM~
N3*123 ANY AVE~
N4*ROSWELL*NM*50313**CY*CHAVES~
DMG*D8*19790810*F**I~
HI*ZZ:3:D8:20140101:150~
For the purposes of this example, the values representing the CMS/CCIIO Enrollment Amounts Code Set reported in the second component of the composite are as follows:
3 = Total Premium Amount
NM1*P5*2*XYZ EMPLOYER*****24*987654321~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
LS*2700~
LX*1~
N1*AG*MONEY TALKS AGENCY*FI*123356799~
REF*0B*123456*PA~
DTP*007*D8*20130915~
LE*2700~
Enrollment information for Jane Buck, employed by DEF Employer, is reported in the following group of segments.
INS*Y*01*021*20*A***AC~
REF*18*654987321~
REF*1L*6542556~
REF*WH*321456987~
REF*POL*987123~
DTP*356*D8*20140101~
NM1*IL*1*BUCK*JANE*R***34*555443216~
PER*IP**TE*2135555555*EM*BUCKJ@EMAIL.COM~
N3*123 SOMEWHERE CT~
N4*ROSWELL*NM*50313**CY*CHAVES~
DMG*D8*19790610*F**I~
HI*ZZ:3:D8:20140101:250~
For the purposes of this example, the value representing the CMS/CCIIO Enrollment Amounts Code Set reported in the second component of the composite is defined as follows:
3 = Total Premium Amount
NM1*P5*2*DEF EMPLOYER*****24*555879654~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
SE*143*0001~