[ X12 Examples ]
Com1 Software 834 Benefit Enrollment Example
Posted: Friday, November 04 2022 5:15:48 PM
Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236
(330) 653-3771
information@com1software.com
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834 Benefit Enrollment Example
Companion Guides
Anthem
User Guide (Employer Group Trading Partner)
834 Benefit Enrollment and Maintenance
834 Benefit Enrollment and Maintenance - Compass Life & Disability
What’s Changing for 5010
834 Benefit Enrollment source file.
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *080319*2327*U*00501*002721171*0*P*:~ GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*005010X220~ ST*834*0001*005010X220A1~ BGN*00*XXX20110524C002*20110325*1115****2~ REF*38*G02472~ DTP*007*D8*20110325~ N1*P5*SUMCARE ENROLL*FI*99-9999999~ N1*IN*SUMCARE*FI*999999999~ INS*Y*18*024*08*C**1*TE~ REF*0F*111224443~ REF*1L*G04559SB~ DTP*337*D8*20110331~ NM1*IL*1*DOE*JANE*I~ PER*IP**HP*3305551212~ N3*486 SOME STREET~ N4*AKRON*OH*44313~ DMG*D8*19670315*F~ HD*024**HLT~ DTP*349*D8*20110331~ INS*Y*18*030*28*A**1*FT~ REF*0F*111224449~ REF*1L*G04550SB~ DTP*336*D8*20100101~ NM1*IL*1*PUBLIC*JOSHUA*C~ PER*IP**HP*3305551313~ N3*486 SOME STREET~ N4*AKRON*OH*44313~ DMG*D8*19670820*M~ HD*030**HLT~ DTP*348*D8*20100401~ INS*N*19*001**A~ REF*0F*111224449~ REF*1L*G04550SB~ NM1*IL*1*PUBLIC*SUSAN~ PER*IP**HP*3305551313~ N3*486 SOME STREET~ N4*AKRON*OH*44313~ DMG*D8*19950315*F~ NM1*70*1*PUBLIC*SUSAN~ DMG*D8*19950326*F~ HD*001**HLT~ DTP*348*D8*20100401~ INS*Y*18*030*28*A**1*FT~ REF*0F*333224449~ REF*1L*G04550SB~ DTP*336*D8*20100101~ NM1*IL*1*JONES*JOE*E~ PER*IP**HP*3305551313~ N3*111 APPLE STREET~ N4*CLEVELAND*OH*44144~ DMG*D8*19670820*M~ HD*030**HLT~ DTP*348*D8*20100401~ INS*N*19*001**A~ REF*0F*111224449~ REF*1L*G04550SB~ NM1*IL*1*JONES*JAN~ PER*IP**HP*3305551313~ N3*111 APPLE STREET~ N4*CLEVELAND*OH*44144~ DMG*D8*19950315*F~ NM1*70*1*PUBLIC*SUSAN~ DMG*D8*19950326*F~ HD*001**HLT~ DTP*348*D8*20100401~ INS*Y*18*021*20*A***FT~ REF*WH*123456789~ REF*POL*123456~ DTP*356*D8*20140101~ NM1*IL*1*DOUGH*JOHN****34*111111111~ PER*IP**TE*2166551234*EM*DOUGHJ@EMAIL.COM~ N3*100 MY WAY~ N4*HUDSON*OH*44236**CY*SUMMIT~ DMG*D8*19600101*M**C~ HLH*T~ HI*ZZ:1:D8:20170101:20*ZZ:2:D8:20170101:30::A*ZZ:3:D8:20170101:100~ NM1*2J*1*DOUGH*JOHN****FI*111111111~ HD*021**HLT**ESP~ DTP*348*D8*20170101~ DTP*300*D8*20181019~ LS*2700~ LX*1~ N1*AG*BSA BENEFITS*FI*99999999~ REF*0B*121212*PA~ DTP*007*D8*20170915~ LE*2700~ INS*N*01*021*20*A***AC~ REF*6O*123456789~ REF*WH*987654321~ REF*POL*123456~ DTP*356*D8*20170101~ NM1*IL*1*DOUGH*JANE****34*222222222~ PER*IP**TE*2169991234*EM*DODOUGHJ@EMAIL.COM~ N3*100 MY WAY~ N4*HUDSON*OH*44236**CY*SUMMIT~ DMG*D8*19601211*F**I~ HI*ZZ:1:D8:20170101:20*ZZ:2:D8:20170101:30::A*ZZ:3:D8:20170101:100~ NM1*2J*1*DOUGH*JOHN****FI*111111111~ HD*021**HLT**ESP~ DTP*348*D8*20170101~ LS*2700~ LX*1~ N1*AG*BSA BENEFITS*FI*99999999X~ REF*0B*121212*PA~ DTP*007*D8*20170915~ LE*2700~ SE*105*0001~ GE*1*27211711~ IEA*1*002721171~
Basic Inline
Base Mapping for the 834
********** Com1 Software Parser Map ********** Generated :07/31/17 07:48:58 ********** (c) 1992-2015 COM1 SOFTWARE DEVELOPMENT ************************************************** ********* File Name : 005010X220.cfg ********* X12 Version 5010 ********* 834 Benefit Enrollment and Maintenance ************************************************** X12TRANSACTIONTYPE=834 VERSION=5010 KEYFIELD=INS KEYLINEFIELD=HD FIELD=TRANSACTIONSETCODE,10,BGN,,,1,,,,1 FIELD=TRANSACTIONSETREFNUM,20,BGN,,,2,,,,1 FIELD=TRANSACTIONDATE,10,BGN,,,3,,,,1 FIELD=TRANSACTIONTIME,10,BGN,,,4,,,,1 FIELD=TRANSACTIONSETIDCODE,10,BGN,,,6,,,,1 FIELD=TRANSACTIONACTIONCODE,10,BGN,,,8,,,,1 FIELD=MASTERPOLICYNUMBER,24,REF,38,2,2,,,,1 FIELD=EFFECTIVEDATE,10,DTP,007,2,3,,,,1 FIELD=MAINTEFFECTIVEDATE,10,DTP,303,2,3,,,,1 FIELD=RENEWEFFECTIVEDATE,10,DTP,382,2,3,,,,1 FIELD=QUANTITYCONTROLQUALIFIER,10,QTY,,,1,,,,1 FIELD=QUANTITYCONTROLAMOUNT,10,QTY,,,2,,,,1 FIELD=PLANSPOSORNAME,16,N1,P5,2,2,,,,1 FIELD=PLANSPOSORID,16,N1,P5,2,4,,,,1 FIELD=INSURERNAME,16,N1,IN,2,2,,,,1 FIELD=INSURERID,16,N1,IN,2,4,,,,1 FIELD=TPANAME,16,N1,TV,2,2,,,,1 FIELD=TPAID,16,N1,TV,2,4,,,,1 FIELD=SUBIND,3,INS,,1,1 FIELD=SUBRELATIONCODE,3,INS,,,2,,SUBIND FIELD=SUBINSMAINTTYPECODE,3,INS,,,3,,SUBIND FIELD=SUBINSREASONCODE,3,INS,,,4,,SUBIND FIELD=SUBBENSTAT,3,INS,,,5,,SUBIND FIELD=SUBMEDICAREPLANCODE,3,INS,,,6,1,SUBIND FIELD=SUBELIGIBILITYREASONCODE,3,INS,,,6,2,SUBIND FIELD=SUBCOBRAQUALEVENT,3,INS,,,7,,SUBIND FIELD=SUBEMPLSTATCODE,3,INS,,,8,,SUBIND FIELD=SUBSTUDENTSTATCODE,3,INS,,,9,,SUBIND FIELD=SUBHANDICAPIND,3,INS,,,10,,SUBIND FIELD=SUBDATEOFDEATH,12,INS,,,12,,SUBIND FIELD=SUBCONFIDENTCODE,3,INS,,,13,,SUBIND FIELD=SUBNUM,20,REF,0F,2,2,,SUBIND FIELD=SUBGRPPOLNUM,20,REF,1L,2,2,,SUBIND FIELD=CLIENTNUM,20,REF,23,2,2,,SUBIND FIELD=DEPTAGENTNUM,20,REF,DX,2,2,,SUBIND FIELD=REPORTCAT,20,REF,17,2,2,,SUBIND FIELD=SUBDATEREC,16,DTP,050,2,3,,SUBIND FIELD=SUBMAINEFFDT,16,DTP,303,2,3,,SUBIND FIELD=SUBHIREDT,16,DTP,336,2,3,,SUBIND FIELD=SUBCOBRASTART,16,DTP,340,2,3,,SUBIND FIELD=SUBCOBRAEND,16,DTP,341,2,3,,SUBIND FIELD=SUBELIGDTSTART,16,DTP,356,2,3,,SUBIND FIELD=SUBELIGDTEND,16,DTP,357,2,3,,SUBIND FIELD=SUBADJHIREDT,16,DTP,383,2,3,,SUBIND FIELD=SUBCREDSERVSTART,16,DTP,385,2,3,,SUBIND FIELD=SUBCREDSERVEND,16,DTP,394,2,3,,SUBIND FIELD=SUBLNAME,32,NM1,IL,2,3,,SUBIND FIELD=SUBFNAME,1,NM1,IL,2,4,,SUBIND FIELD=SUBMI,1,NM1,IL,2,5,,SUBIND FIELD=SUBCOMMQUAL1,16,PER,,,3,,SUBIND FIELD=SUBCOMMNUM1,16,PER,,,4,,SUBIND FIELD=SUBCOMMQUAL2,16,PER,,,5,,SUBIND FIELD=SUBCOMMNUM2,16,PER,,,6,,SUBIND FIELD=SUBCOMMQUAL3,16,PER,,,7,,SUBIND FIELD=SUBCOMMNUM3,16,PER,,,8,,SUBIND FIELD=SUBADDR1,30,N3,,,1,,SUBLNAME FIELD=SUBADDR2,30,N3,,,2,,SUBLNAME FIELD=SUBCITY,30,N4,,,1,,SUBLNAME FIELD=SUBST,2,N4,,,2,,SUBLNAME FIELD=SUBZIP,10,N4,,,3,,SUBLNAME FIELD=SUBSEX,1,DMG,,,3,,SUBLNAME FIELD=SUBSTATUS,1,DMG,,,4,,SUBLNAME FIELD=SUBDOB,10,DMG,,,2,,SUBLNAME FIELD=SUBCOVERAGETYPECODE1,10,HD,,,1,,,,,1 FIELD=SUBCOVERAGELINECODE1,10,HD,,,3,,,,,1 FIELD=SUBCOVERAGEPLANCODE1,10,HD,,,4,,,,,1 FIELD=SUBCOVERAGELEVELCODE1,10,HD,,,5,,,,,1 FIELD=SUBCOVERAGEMAINTDATE1,10,DTP,303,2,3,,,,,1 FIELD=SUBCOVERAGESTARTDATE1,10,DTP,348,2,3,,,,,1 FIELD=SUBCOVERAGEENDDATE1,10,DTP,349,2,3,,,,,1 FIELD=SUBCOVERAGELASTPAIDDATE1,10,DTP,543,2,3,,,,,1 FIELD=SUBPCPLNAME,32,NM1,P3,2,3,,,,,1 FIELD=SUBPCPFNAME,1,NM1,P3,2,4,,,,,1 FIELD=SUBPCPMI,1,NM1,P3,2,5,,,,,1 FIELD=SUBPCPID,1,NM1,P3,2,9,,,,,1 FIELD=MEMIND,3,INS,N,1,1 FIELD=MEMRELATIONCODE,3,INS,,,2,,MEMIND FIELD=MEMINSMAINTTYPECODE,3,INS,,,3,,MEMIND FIELD=MEMINSREASONCODE,3,INS,,,4,,MEMIND FIELD=MEMBENSTAT,3,INS,,,5,,MEMIND FIELD=MEMMEDICAREPLANCODE,3,INS,,,6,1,MEMIND FIELD=MEMELIGIBILITYREASONCODE,3,INS,,,6,2,MEMIND FIELD=MEMCOBRAQUALEVENT,3,INS,,,7,,MEMIND FIELD=MEMEMPLSTATCODE,3,INS,,,8,,MEMIND FIELD=MEMSTUDENTSTATCODE,3,INS,,,9,,MEMIND FIELD=MEMHANDICAPIND,3,INS,,,10,,MEMIND FIELD=MEMDATEOFDEATH,12,INS,,,12,,MEMIND FIELD=MEMCONFIDENTCODE,3,INS,,,13,,MEMIND FIELD=MEMNUM,20,REF,0F,2,2,,MEMIND FIELD=MEMGRPPOLNUM,20,REF,1L,2,2,,MEMIND FIELD=MEMMEMNUM,20,REF,0F,2,2,,MEMIND FIELD=MEMDATEREC,16,DTP,050,2,3,,MEMIND FIELD=MEMMAINEFFDT,16,DTP,303,2,3,,MEMIND FIELD=MEMHIREDT,16,DTP,336,2,3,,MEMIND FIELD=MEMCOBRASTART,16,DTP,340,2,3,,MEMIND FIELD=MEMCOBRAEND,16,DTP,341,2,3,,MEMIND FIELD=MEMELIGDTSTART,16,DTP,356,2,3,,MEMIND FIELD=MEMELIGDTEND,16,DTP,357,2,3,,MEMIND FIELD=MEMADJHIREDT,16,DTP,383,2,3,,MEMIND FIELD=MEMCREDSERVSTART,16,DTP,385,2,3,,MEMIND FIELD=MEMCREDSERVEND,16,DTP,394,2,3,,MEMIND FIELD=MEMLNAME,32,NM1,IL,2,3,,MEMIND FIELD=MEMFNAME,1,NM1,IL,2,4,,MEMIND FIELD=MEMMI,1,NM1,IL,2,5,,MEMIND FIELD=MEMCOMMQUAL1,16,PER,,,3,,MEMIND FIELD=MEMCOMMNUM1,16,PER,,,4,,MEMIND FIELD=MEMCOMMQUAL2,16,PER,,,5,,MEMIND FIELD=MEMCOMMNUM2,16,PER,,,6,,MEMIND FIELD=MEMCOMMQUAL3,16,PER,,,7,,MEMIND FIELD=MEMCOMMNUM3,16,PER,,,8,,MEMIND FIELD=MEMADDR1,30,N3,,,1,,MEMLNAME FIELD=MEMADDR2,30,N3,,,2,,MEMLNAME FIELD=MEMCITY,30,N4,,,1,,MEMLNAME FIELD=MEMST,2,N4,,,2,,MEMLNAME FIELD=MEMZIP,10,N4,,,3,,MEMLNAME FIELD=MEMSEX,1,DMG,,,3,,MEMLNAME FIELD=MEMSTATUS,1,DMG,,,4,,MEMLNAME FIELD=MEMDOB,10,DMG,,,2,,MEMLNAME FIELD=MEMCOVERAGETYPECODE1,10,HD,,,1,,,,,1 FIELD=MEMCOVERAGELINECODE1,10,HD,,,3,,,,,1 FIELD=MEMCOVERAGEPLANCODE1,10,HD,,,4,,,,,1 FIELD=MEMCOVERAGELEVELCODE1,10,HD,,,5,,,,,1 FIELD=MEMCOVERAGEMAINTDATE1,10,DTP,303,2,3,,,,,1 FIELD=MEMCOVERAGESTARTDATE1,10,DTP,348,2,3,,,,,1 FIELD=MEMCOVERAGEENDDATE1,10,DTP,349,2,3,,,,,1 FIELD=MEMCOVERAGELASTPAIDDATE1,10,DTP,543,2,3,,,,,1 FIELD=MEMPCPLNAME,32,NM1,P3,2,3,,,,,1 FIELD=MEMPCPFNAME,1,NM1,P3,2,4,,,,,1 FIELD=MEMPCPMI,1,NM1,P3,2,5,,,,,1 FIELD=MEMPCPID,1,NM1,P3,2,9,,,,,1 FIELD=SOURCEFILE,64,,,,,,,,5 FIELD=DESTINATIONFILE,64,,,,,,,,6 ************************************* X12 Out Mapping SEGMENT=1,BGN,00,$TRANSACTIONSETREFNUM,$TRANSACTIONDATE,$TRANSACTIONTIME,,$TRANSACTIONSETIDCODE,,$TRANSACTIONACTIONCODE SEGMENT=1,REF:$MASTERPOLICYNUMBER,38,$MASTERPOLICYNUMBER SEGMENT=1,DTP:$EFFECTIVEDATE,007,$EFFECTIVEDATE SEGMENT=1,DTP:$MAINTEFFECTIVEDATE,303,$MAINTEFFECTIVEDATE SEGMENT=1,DTP:$RENEWEFFECTIVEDATE,382,$RENEWEFFECTIVEDATE SEGMENT=1,QTY:$QUANTITYCONTROLAMOUNT,$QUANTITYCONTROLQUALIFIER,$QUANTITYCONTROLAMOUNT SEGMENT=1,N1:$PLANSPOSORNAME,P5,$PLANSPOSORNAME,FI,$PLANSPOSORID SEGMENT=1,N1:$INSURERNAME,IN,$INSURERNAME,FI,$INSURERID SEGMENT=1,N1:$TPANAME,TV,$TPANAME,FI,$TPAID SEGMENT=2,INS:$SUBIND,$SUBIND,$SUBRELATIONCODE,$SUBINSMAINTTYPECODE,$SUBINSREASONCODE,$SUBBENSTAT,$SUBMEDICAREPLANCODE;$SUBELIGIBILITYREASONCODE,$SUBCOBRAQUALEVENT,$SUBEMPLSTATCODE,$SUBSTUDENTSTATCODE,$SUBHANDICAPIND,,$SUBDATEOFDEATH,$SUBCONFIDENTCODE SEGMENT=2,REF:$SUBNUM,0F,$SUBNUM SEGMENT=2,REF:$SUBGRPPOLNUM,1L,$SUBGRPPOLNUM SEGMENT=2,REF:$CLIENTNUM,23,$CLIENTNUM SEGMENT=2,REF:$DEPTAGENTNUM,DX,$DEPTAGENTNUM SEGMENT=2,REF:$REPORTCAT,17,$REPORTCAT SEGMENT=2,DTP:$SUBDATEREC,050,D8,$SUBDATEREC SEGMENT=2,DTP:$SUBMAINEFFDT,303,D8,$SUBMAINEFFDT SEGMENT=2,DTP:$SUBHIREDT,336,D8,$SUBHIREDT SEGMENT=2,DTP:$SUBCOBRASTART,340,D8,$SUBCOBRASTART SEGMENT=2,DTP:$SUBCOBRAEND,341,D8,$SUBCOBRAEND SEGMENT=2,DTP:$SUBELIGDTSTART,356,D8,$SUBELIGDTSTART SEGMENT=2,DTP:$SUBELIGDTEND,357,D8,$SUBELIGDTEND SEGMENT=2,DTP:$SUBADJHIREDT,383,D8,$SUBADJHIREDT SEGMENT=2,DTP:$SUBCREDSERVSTART,385,D8,$SUBCREDSERVSTART SEGMENT=2,DTP:$SUBCREDSERVEND,394,D8,$SUBCREDSERVEND SEGMENT=2,NM1:$SUBLNAME,IL,1,$SUBLNAME,$SUBFNAME,$SUBMI SEGMENT=2,PER:$SUBCOMMNUM1,IP,,$SUBCOMMQUAL1,$SUBCOMMNUM1,$SUBCOMMQUAL2,$SUBCOMMNUM2,$SUBCOMMQUAL3,$SUBCOMMNUM3 SEGMENT=2,N3:$SUBADDR1,$SUBADDR1,$SUBADDR2 SEGMENT=2,N4:$SUBCITY,$SUBCITY,$SUBST,$SUBZIP SEGMENT=2,DMG:$SUBDOB,D8,$SUBDOB,$SUBSEX,$SUBSTATUS SEGMENT=3,HD:$SUBCOVERAGETYPECODE,$SUBCOVERAGETYPECODE,,$SUBCOVERAGELINECODE,$SUBCOVERAGEPLANCODE,$SUBCOVERAGELEVELCODE SEGMENT=3,DTP:$SUBCOVERAGEMAINTDATE,303,D8,$SUBCOVERAGEMAINTDATE SEGMENT=3,DTP:$SUBCOVERAGESTARTDATE,348,D8,$SUBCOVERAGESTARTDATE SEGMENT=3,DTP:$SUBCOVERAGEENDDATE,349,D8,$SUBCOVERAGEENDDATE SEGMENT=3,DTP:$SUBCOVERAGELASTPAIDDATE,543,D8,$SUBCOVERAGELASTPAIDDATE SEGMENT=3,LX:$MEMPCPID,1 SEGMENT=3,NM1:$MEMPCPID,P3,1,,,,,,XX,$MEMPCPID SEGMENT=2,INS:$MEMIND,$MEMIND,$MEMRELATIONCODE,$MEMINSMAINTTYPECODE,$MEMINSREASONCODE,$MEMBENSTAT,$MEMMEDICAREPLANCODE;$MEMELIGIBILITYREASONCODE,$MEMCOBRAQUALEVENT,$MEMEMPLSTATCODE,$MEMSTUDENTSTATCODE,$MEMHANDICAPIND,,$MEMDATEOFDEATH,$MEMCONFIDENTCODE SEGMENT=2,REF:$MEMNUM,0F,$MEMNUM SEGMENT=2,REF:$MEMGRPPOLNUM,1L,$MEMGRPPOLNUM SEGMENT=2,DTP:$MEMDATEREC,050,D8,$MEMDATEREC SEGMENT=2,DTP:$MEMMAINEFFDT,303,D8,$MEMMAINEFFDT SEGMENT=2,DTP:$MEMHIREDT,336,D8,$MEMHIREDT SEGMENT=2,DTP:$MEMCOBRASTART,340,D8,$MEMCOBRASTART SEGMENT=2,DTP:$MEMCOBRAEND,341,D8,$MEMCOBRAEND SEGMENT=2,DTP:$MEMELIGDTSTART,356,D8,$MEMELIGDTSTART SEGMENT=2,DTP:$MEMELIGDTEND,357,D8,$MEMELIGDTEND SEGMENT=2,DTP:$MEMADJHIREDT,383,D8,$MEMADJHIREDT SEGMENT=2,DTP:$MEMCREDSERVSTART,385,D8,$MEMCREDSERVSTART SEGMENT=2,DTP:$MEMCREDSERVEND,394,D8,$MEMCREDSERVEND SEGMENT=2,NM1:$MEMLNAME,IL,1,$MEMLNAME,$MEMFNAME,$MEMMI SEGMENT=2,PER:$MEMCOMMNUM1,IP,,$MEMCOMMQUAL1,$MEMCOMMNUM1,$MEMCOMMQUAL2,$MEMCOMMNUM2,$MEMCOMMQUAL3,$MEMCOMMNUM3 SEGMENT=2,N3:$MEMADDR1,$MEMADDR1,$MEMADDR2 SEGMENT=2,N4:$MEMCITY,$MEMCITY,$MEMST,$MEMZIP SEGMENT=2,DMG:$MEMDOB,D8,$MEMDOB,$MEMSEX,$MEMSTATUS SEGMENT=3,HD:$MEMCOVERAGETYPECODE,$MEMCOVERAGETYPECODE,,$MEMCOVERAGELINECODE,$MEMCOVERAGEPLANCODE,$MEMCOVERAGELEVELCODE SEGMENT=3,DTP:$MEMCOVERAGEMAINTDATE,303,D8,$MEMCOVERAGEMAINTDATE SEGMENT=3,DTP:$MEMCOVERAGESTARTDATE,348,D8,$MEMCOVERAGESTARTDATE SEGMENT=3,DTP:$MEMCOVERAGEENDDATE,349,D8,$MEMCOVERAGEENDDATE SEGMENT=3,DTP:$MEMCOVERAGELASTPAIDDATE,543,D8,$MEMCOVERAGELASTPAIDDATE SEGMENT=3,LX:$SUBPCPID,1 SEGMENT=3,NM1:$SUBPCPID,P3,1,,,,,,XX,$SUBPCPID