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