834 Benefit Enrollment and Maintenance (X220A1)
X12 HIPAA · X12 005010X220A1
X12 HIPAA’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
74 of 74 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 —
1000C LoopTPA/Broker Name Looprepeats 2
N1
TPA/Broker Name
- Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.
pos 0700
Required
max —
1100C LoopTPA/Broker Account Information Loop
ACT
TPA/Broker Account Information
- Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.
pos 1200
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
Subscriber Identifiervariant 1 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 —
REF
Member Policy Numbervariant 2 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 3 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
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 —
PER
Member Communications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
N3
Member Residence Street Address
- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Member City, State, ZIP Code
- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
pos 0600
Optional
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 —
EC
Employment Class
- Required when sending additional employment class information on the member. If not required by this implementation guide, do not send.
pos 1000
Optional
max —
ICM
Member Income
- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
pos 1100
Optional
max —
AMT
Member Policy Amounts
- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
pos 1200
Optional
max 7
HLH
Member Health Information
- Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send.
pos 1300
Optional
max —
LUI
Member Language
Required when a value is being reported in the LUI02 element. If not required by this implementation guide, do not send.
- Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.
- Any need to send/collect this information will need to be contained in the trading partner agreement.
pos 1500
Optional
max —
2100B LoopIncorrect Member Name Loop
NM1
Incorrect Member Name
- Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.
- If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.
pos 0300
Required
max —
DMG
Incorrect Member Demographics
Required when the members birth date is being corrected. If not required by this implementation guide, do not send.
- Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.
pos 0800
Optional
max —
2100C LoopMember Mailing Address Loop
NM1
Member Mailing Address
- Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send.
pos 0300
Required
max —
N3
Member Mail Street Address
pos 0500
Required
max —
N4
Member Mail City, State, ZIP Code
pos 0600
Required
max —
2100D LoopMember Employer Looprepeats 3
NM1
Member Employer
- Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.
- This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop.
pos 0300
Required
max —
PER
Member Employer Communications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
N3
Member Employer Street Address
- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Member Employer City, State, ZIP Code
- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
2100E LoopMember School Looprepeats 3
NM1
Member School
- Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
pos 0300
Required
max —
PER
Member School Commmunications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
N3
Member School Street Address
- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Member School City, State, ZIP Code
- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
2100F LoopCustodial Parent Loop
NM1
Custodial Parent
- Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.
- Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment.
pos 0300
Required
max —
PER
Custodial Parent Communications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
N3
Custodial Parent Street Address
- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Custodial Parent City, State, ZIP Code
- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
2100G LoopResponsible Person Looprepeats 13
NM1
Responsible Person
- Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send.
pos 0300
Required
max —
PER
Responsible Person Communications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0400
Optional
max —
N3
Responsible Person Street Address
- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Responsible Person City, State, ZIP Code
- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
2100H LoopDrop Off Location Loop
NM1
Drop Off Location
- Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.
pos 0300
Required
max —
N3
Drop Off Location Street Address
- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
pos 0500
Optional
max —
N4
Drop Off Location City, State, ZIP Code
- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
pos 0600
Optional
max —
2200 LoopDisability Information Loop
DSB
Disability Information
- Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send.
pos 2000
Required
max —
DTP
Disability Eligibility Dates
- This segment is used to send the first and last date of disability.
- Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.
pos 2100
Optional
max 2
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
AMT
Health Coverage Policy
- Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
pos 2800
Optional
max 9
REF
Health Coverage Policy Numbervariant 1 of 2
- 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
REF
Prior Coverage Monthsvariant 2 of 2
- Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act.
pos 2900
Optional
max —
IDC
Identification Card
- Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.
- An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card.
pos 3000
Optional
max 3
2310 LoopProvider Information Looprepeats 30
LX
Provider Information
- Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.
- Use one iteration of the loop to identify each applicable health care service provider.
- The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.
pos 3100
Required
max —
NM1
Provider Name
- The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2.
pos 3200
Required
max —
N3
Provider Address
- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
pos 3500
Optional
max 2
N4
Provider City, State, ZIP Code
- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
pos 3600
Optional
max —
PER
Provider Communications Numbers
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
- Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send.
pos 3700
Optional
max 2
PLA
Provider Change Reason
- Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.
pos 3950
Optional
max —
2320 LoopCoordination of Benefits Looprepeats 5
COB
Coordination of Benefits
- Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.
pos 4000
Required
max —
REF
Additional Coordination of Benefits Identifiers
- Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
- Use the Social Security Number until the National ID Number for individuals is available.
pos 4050
Optional
max 4
DTP
Coordination of Benefits Eligibility Dates
- Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send.
pos 4070
Optional
max 2
2330 LoopCoordination of Benefits Related Entity Looprepeats 3
NM1
Coordination of Benefits Related Entity
- Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send.
pos 4100
Required
max —
N3
Coordination of Benefits Related Entity Address
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
pos 4300
Optional
max —
N4
Coordination of Benefits Other Insurance Company City, State, ZIP Code
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
pos 4400
Optional
max —
PER
Administrative Communications Contact
- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
pos 4500
Optional
max —
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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