ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X307
Example 01: Enroll Individuals in a Qualified Health Plan through a Health Insurance Exchange
John Doe is enrolling himself as well as his spouse in a Qualified Health Plan (QHP) through a Health Insurance Exchange (HIX). John Doe is self-employed and is not eligible to enroll through the SHOP Exchange.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*2~
QTY*DT*1~
QTY*ET*1~
N1*41*EXCHANGE*46*999888778~
N1*40*RECEIVER*46*999888777~
N1*IN*ISSUER*FI*654456654~
Table 2
INS*Y*18*021*20*A***FT~
REF*WH*123456789~
REF*POL*123456~
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:1:D8:20140101:20*ZZ:2:D8:20140101:30::A*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:
1 = Advanced Premium Tax Credit
2 = Cost Sharing Reduction
3 = Total Premium Amount
For the purposes of this example, the values representing the Cost Sharing Indicator reported in the seventh component of the composite are as follows:
A = 100 – 150% of Federal Poverty Level
NM1*2J*1*DOE*JOHN*P***FI*999888777~
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~
INS*N*01*021*20*A***AC~
REF*6O*456789123~
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:1:D8:20140101:20*ZZ:2:D8:20140101:30::A*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:
1 = Advanced Premium Tax Credit
2 = Cost Sharing Reduction
3 = Total Premium Amount
For the purposes of this example, the values representing the Cost Sharing Indicator reported in the seventh component of the composite are as follows:
A = 100 – 150% of Federal Poverty Level
NM1*2J*1*DOE*JOHN*P***FI*999888777~
HD*021**HLT**ESP~
DTP*348*D8*20140101~
LS*2700~
LX*1~
N1*AG*MONEY TALKS AGENCY*FI*123356799A~
REF*0B*123456*PA~
DTP*007*D8*20130915~
LE*2700~
SE*52*0001~