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*YMember Level Detail
REF*OFSubscriber Number
REF*1LGroup Sub-location Division (GSD)
DTP*336Hire date
NMIEmployee Name
N3Employee Street Address
N4Employee City, State, Zip, Country
DMGMember Demographics
HDCoverage Data
DTP*348Coverage Dates
DTP*349Coverage End Date
INS*NDependent

 

Segment Details – Member Level Detail
INS*Y*18*030*XN*A*E**FT~

INSConstant Value
Y or NY = subscriber (Employee); N= dependent
18Relationship Code = 18 = Employee; 01=Spouse; 19=Child
030030=Full File
XNReason Code
AStatus Code A=Active; C=COBRA
EMedicare Plan Code E=No Medicare; D= Medicare
COBRA Qualifying
FTEmployee Status FT= Full-Time; PT=Part-Time

 

REF*OF – Subscriber Number 
REF*OF*152239999~

REFConstant Value
OFConstant Value
152239999Employees SSN — no dashes (Does not pad with zeros)

 

REF*1L – Account Structure
REF*1L*Blue~

REFConstant Value
1LConstant Value
BlueValue determined by vendor/client

 

DTP*336 – Hire Date
DTP*336*D8*20070101~

DTPConstant Value
336Constant Value
D8Constant Value
20070101YYYYMMDD – Most recent hire date

 

NM1 – Employee Name
NM1*IL*1*BLUTH*LUCILLE****34*152239999~

NM1Constant Value
ILConstant Value
1Constant Value
BLUTHEmployee Last Name
LUCILLEEmployee First Name
Middle Name
Prefix
Suffix
34Constant Value (SSN coming)
152239999Member SSN

 

N3 – Employee Street Address
N3*224 N DES PLAINES*6TH FLOOR~

N3Constant Value
224 N DES PLAINESEmployee Address Line 1 (No punctuation)
6TH FLOOREmployee Address Line 2 (No punctuation)

 

N4 – Employee City, State, Zip
N4*CHICAGO*IL*60661*USA~

N4Constant Value
CHICAGOEmployee Address City
ILEmployee Address State
60661Employee Address Zip Code
USAEmployee Address Country

 

DMG*8 – Member Demographics
DMG*D8*19720121*F*M~

DMGConstant Value
D8Constant Value
19720121Date of Birth
FGender F=Female; M=Male; U=Unknown
MMarital Status M=Married; I=Single; D=Divorced; X=Legally Separated; R=Unreported

 

HD – Health Coverage
HD*030**VIS**EMP~

HDConstant Value
030030=Full File
Reason – may not be required
VISInsurance Code – see Specs
Coverage Description – may not be required
MPCoverage 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~

DTPConstant Value
348Constant Value
D8Constant Value
20111016Benefit Begin Date

 

DTP*349 – Health Coverage End Dates
DTP*349*D8*20111015~

DTPConstant Value
349Constant Value
D8Constant Value
20111016Benefit Termination Date

 

INS Segment – Member Level Detail
INS*N*19*030*XN*A*E***N*N~

INSConstant Value
NN= dependent
18Relationship Code = 18 = Employee; 01=Spouse; 19=Child
030030=Full File
XNReason Code (may or may not be used)
AStatus Code A=Active; C=COBRA; S=Surviving Spouse
EMedicare 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