834 (FFE Issuer to FFE) 834 Benefit Enrollment and Maintenance (X220A1) v7.0
Centers for Medicare & Medicaid Services (CMS) · X12 005010X220A1
Centers for Medicare & Medicaid Services (CMS)’s published 834 specification, rendered as an interactive guide. Expand any segment to see its elements, data types, lengths and accepted codes — then validate your own document against it below.
Specification
22 of 22 segments
HEADING
ST
Transaction Set Header
pos 0100
Optional
max —
BGN
Beginning Segment
pos 0200
Required
max —
REF
Transaction Set Policy Number
- The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.
- Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set.
pos 0300
Optional
max —
DTP
File Effective Date
- Required when specified in the contract. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
QTY
Transaction Set Control Totals
- Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send.
pos 0600
Optional
max 3
1000A LoopSponsor Name Looprequired
N1
Sponsor Name
- This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
pos 0700
Required
max —
1000B LoopPayer Looprequired
N1
Payer
- This loop identifies the payer. See section 1.5 for the definition of payer.
pos 0700
Required
max —
DETAIL
2000 LoopMember Level Detail Looprequired
INS
Member Level Detail
- Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.
pos 0100
Required
max —
REF
Member Policy Numbervariant 1 of 3
- The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.
- Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send.
pos 0200
Optional
max —
REF
Member Supplemental Identifiervariant 2 of 3
- Required when sending additional identifying information on the member. If not required by this implementation guide, do not send.
pos 0200
Optional
max 13
REF
Subscriber Identifiervariant 3 of 3
- This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
- The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available.
pos 0200
Required
max —
DTP
Member Level Dates
- Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.
- While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective.
pos 0250
Optional
max 24
2100A LoopMember Name Looprequired
NM1
Member Name
pos 0300
Required
max —
DMG
Member Demographics
- Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send.
pos 0800
Optional
max —
2300 LoopHealth Coverage Looprepeats 99
HD
Health Coverage
- Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.
- Refer to section 1.4.4 "Termination" for additional information relative to removing a member's coverage.
pos 2600
Required
max —
DTP
Health Coverage Dates
pos 2700
Required
max 6
REF
Health Coverage Policy Number
- Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send.
pos 2900
Optional
max 14
2700 LoopMember Reporting Categories Loop
LX
Member Reporting Categories
- Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.
pos 6881
Required
max —
2750 LoopReporting Category Loop
N1
Reporting Category
- Required to specify the name of the reporting category of the member's participating entity.
pos 6882
Required
max —
REF
Reporting Category Reference
- Required to specify the reference identifier associated with the reporting category of the member's participating entity.
pos 6883
Optional
max —
DTP
Reporting Category Date
- Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
- Use this segment to associate a date or date range with a reporting category.
pos 6884
Optional
max —
SE
Transaction Set Trailer
pos 6900
Optional
max —
Validate a 834
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