HIPAA ANSI 834 File Layout: The 834 transaction represents a computer “benefit enrollment and maintenance document.” It is commonly used to communicate health plan enrollment information.

Sample File Output

INS*Y*18*030*XN*A*E**FT~

REF*OF*152239999~

REF*1L*Blue~

DTP*336*D8*20070101~

NM1*IL*1*BLUTH*LUCILLE****34*152239999~

N3*224 N DES PLAINES*6TH FLOOR~

N4*CHICAGO*IL*60661*USA~

DMG*D8*19720121*F*M~

HD*030**VIS**EMP~

DTP*348*D8*20111016~

INS*N*19*030*XN*A*E***N*N~

REF*OF*152239999~

REF*1L*Blue~

DTP*357*D8*20111015~

NM1*IL*1*BLUTH*BUSTER~

N3*224 N DES PLAINES*6TH FLOOR~

N4*CHICAGO*IL*60661*USA~

DMG*D**19911015*M-HD*030**VIS~

DTP*348*D8*20110101~

DTP*349*D8*20111015~

INS*Y Member Level Detail REF*OF Subscriber Number REF*1L Group Sub-location Division (GSD) DTP*336 Hire date NMI Employee Name N3 Employee Street Address N4 Employee City, State, Zip, Country DMG Member Demographics HD Coverage Data DTP*348 Coverage Dates DTP*349 Coverage End Date INS*N Dependent

Segment Details – Member Level Detail

INS*Y*18*030*XN*A*E**FT~

INS Constant Value Y or N Y = subscriber (Employee); N= dependent 18 Relationship Code = 18 = Employee; 01=Spouse; 19=Child 030 030=Full File XN Reason Code A Status Code A=Active; C=COBRA E Medicare Plan Code E=No Medicare; D= Medicare COBRA Qualifying FT Employee Status FT= Full-Time; PT=Part-Time

REF*OF – Subscriber Number

REF*OF*152239999~

REF Constant Value OF Constant Value 152239999 Employees SSN — no dashes (Does not pad with zeros)

REF*1L – Account Structure

REF*1L*Blue~

REF Constant Value 1L Constant Value Blue Value determined by vendor/client

DTP*336 – Hire Date

DTP*336*D8*20070101~

DTP Constant Value 336 Constant Value D8 Constant Value 20070101 YYYYMMDD – Most recent hire date

NM1 – Employee Name

NM1*IL*1*BLUTH*LUCILLE****34*152239999~

NM1 Constant Value IL Constant Value 1 Constant Value BLUTH Employee Last Name LUCILLE Employee First Name Middle Name Prefix Suffix 34 Constant Value (SSN coming) 152239999 Member SSN

N3 – Employee Street Address

N3*224 N DES PLAINES*6TH FLOOR~

N3 Constant Value 224 N DES PLAINES Employee Address Line 1 (No punctuation) 6TH FLOOR Employee Address Line 2 (No punctuation)

N4 – Employee City, State, Zip

N4*CHICAGO*IL*60661*USA~

N4 Constant Value CHICAGO Employee Address City IL Employee Address State 60661 Employee Address Zip Code USA Employee Address Country

DMG*8 – Member Demographics

DMG*D8*19720121*F*M~

DMG Constant Value D8 Constant Value 19720121 Date of Birth F Gender F=Female; M=Male; U=Unknown M Marital Status M=Married; I=Single; D=Divorced; X=Legally Separated; R=Unreported

HD – Health Coverage

HD*030**VIS**EMP~

HD Constant Value 030 030=Full File Reason – may not be required VIS Insurance Code – see Specs Coverage Description – may not be required MP Coverage Level/Tier EMP=Employee; ESP= Employee + Spouse; FAM = Family; ECH = Employee + Children; TWO = Employee & 1 Dep; E1D = Employee & 1 Child

DTP*348 – Health overage Dates

DTP*348**D820111016~

DTP Constant Value 348 Constant Value D8 Constant Value 20111016 Benefit Begin Date

DTP*349 – Health Coverage End Dates

DTP*349*D8*20111015~

DTP Constant Value 349 Constant Value D8 Constant Value 20111016 Benefit Termination Date

INS Segment – Member Level Detail

INS*N*19*030*XN*A*E***N*N~

INS Constant Value N N= dependent 18 Relationship Code = 18 = Employee; 01=Spouse; 19=Child 030 030=Full File XN Reason Code (may or may not be used) A Status Code A=Active; C=COBRA; S=Surviving Spouse E Medicare Plan Code E=No Medicare; B= Medicare Part B; D= Medicare COBRA Qualifying Event Employee Status FT= Full-Time; PT=Part-Time Student Status F=Full Time; N= Not a Student Handicap Indicator Y=Yes; N= No

Segments repeat for the dependent