834 Benefit Enrollments and Maintenance 5010
Companion Guide
HIPAA/V5010220A1/834
Version 1.1
Company: Blue Cross of Idaho
Created 05/29/2013
An Independent Licensee of the Blue Cross and Blue Shield Association
Table of Contents
834
Benefit Enrollment and Maintenance ............................................................................................................................
ISA
Interchange Control Header .................................................................................................................................... 5
GS
Functional Group Header ........................................................................................................................................ 6
ST
Transaction Set Header ............................................................................................................................................ 6
BGN
Beginning Segment ................................................................................................................................................... 7
REF
Transaction Set Policy Number ............................................................................................................................... 7
DTP
File Effective Date ..................................................................................................................................................... 8
QTY
Transaction Set Control Total ................................................................................................................................. 8
1000A
N1
Sponsor Name ........................................................................................................................................................... 8
1000B
Loop Payer
N1
Payer .......................................................................................................................................................................... 9
1000C
Loop TPA/Broker Name
N1
TPA/Broker Name .................................................................................................................................................... 9
1100C
Loop TPA/Broker Account Information
ACT
TPA/Broker Account Information ........................................................................................................................ 10
2000
Loop Member Level Detail
INS
Member Level Detail .............................................................................................................................................. 11
REF
Subscriber Identifier............................................................................................................................................... 12
REF
Member Policy Number ......................................................................................................................................... 12
REF
Member Supplemental Identifier .......................................................................................................................... 13
DTP
Member Level Dates ............................................................................................................................................... 14
2100A
Loop Member Name
NM1
Member Name ......................................................................................................................................................... 15
PER
Member Communications Numbers ..................................................................................................................... 15
N3
Member Residence Street Address ........................................................................................................................ 16
N4
Member City, State, ZIP Code .............................................................................................................................. 16
DMG
Member Demographics .......................................................................................................................................... 17
2300
Loop Health Coverage
HD
Health Coverage...................................................................................................................................................... 18
DTP
Health Coverage Dates ........................................................................................................................................... 19
REF
Health Coverage Policy Number ........................................................................................................................... 19
2310
Loop Provider Information
LX
Provider Information ............................................................................................................................................. 19
2500
Loop Flexible Spending Account
FSA
Flexible Spending Account ..................................................................................................................................... 20
AMT
Monetary Amount Information ............................................................................................................................. 21
DTP
Date or Time or Period ........................................................................................................................................... 21
SE
GE
IEA
Transaction Set Trailer .......................................................................................................................................... 22
Functional Group Trailer ....................................................................................................................................... 22
Interchange Control Trailer .................................................................................................................................. 22
2
1 Introduction
1.1 Disclaimer
Blue Cross of Idaho (BCI) created this Companion Guide for the 835 Health Care Claim
Payment Advice to use in conjunction with the 5010A1 version of the ANSI X12
Implementation Guide. This document is not a replacement for the ANSI X12 Implementation
Guide, but an additional source of information created to assist providers and business partners
of Blue Cross of Idaho. You can download a free copy of the latest ANSI X12 Implementation
Guide at wpc-edi.com/content/view/533/377/.
Blue Cross of Idaho ONLY provides remittances for Blue Cross of Idaho claims
1.2 Document Purpose
The purpose of this companion guide is to describe those aspects of processing an electronic 835
Health Care Claims Payment Advice that are specific to Blue Cross of Idaho.
This companion guide contains data clarifications derived from specific business rules that apply
exclusively to claims processing done by Blue Cross of Idaho. In addition, this guide also
includes useful information about sending and receiving data to and from Blue Cross of Idaho.
Though Blue Cross of Idaho continually updates this document, the current version is always
available on the website bcidaho.com/edi_clearinghouse/index.asp
2 Enrollment
2.1 Enrollment Information
Any entity desiring to send or receive electronic transactions through the Blue Cross of Idaho
Clearinghouse must first be registered. Blue Cross of Idaho accepts one enrollment form for
multiple transactions. If you are interested in registering with Blue Cross of Idaho, simply
complete a copy of the Electronic Data Interchange (EDI) Enrollment Form available at
bcidaho.com/edi_clearinghouse/index.asp and fax it to 208-331-7203.
If you are a vendor, please select Vendor EDI Enrollment Form in the vendor column.
Providers need to select EDI Enrollment Form from the provider column.
835 Remittances Advise Blue Cross of Idaho ONLY provides remittances for Blue Cross of
Idaho claims.
After Blue Cross of Idaho receives and processes your Electronic Claims Submission Enrollment
Form, there are a number of tasks that must be completed:
 Receive your login and password information.
 Submit test files, assisted by a member of the Blue Cross of Idaho EDI Support Desk.
 Obtain permission to submit production data files.
2.2
EDI Support
3
The Blue Cross of Idaho EDI Support Desk assists users with questions about electronic
transactions. The Blue Cross of Idaho EDI Support Desk is available to all Idaho providers and
vendors Monday through Friday from 8:00 a.m. to 5:00 p.m. MST at 208-331-8817 or
888-224-3341. The Blue Cross of Idaho EDI Support Desk:
 Provides information on services offered
 Enrolls users for claims submission and data retrieval and vendors for 27x transactions
 Verifies receipt of electronic transmissions
 Provides technical assistance to users who are experiencing transmission difficulties
2.3 General Business Information
Blue Cross of Idaho will only accept transactions from trading partners that completed the
enrollment process and have a submitter ID on file. We will reject all other transactions.
Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements
used by Blue Cross of Idaho, but remember the eligibility information returned by Blue Cross of
Idaho is not a guarantee of claims payment. Blue Cross of Idaho responds to all eligibility
requests with the coverage information available for the patient identified per the date provided.
3.1 Blue Cross of Idaho Business Rules
Blue Cross of Idaho complies with HIPAA regulations. Blue Cross of Idaho’s specific business
rules regarding HIPAA Claims Adjustment Reason Codes (Loop 2110 / Segment CAS) and
HIPAA Remittance Advice Remark Codes (Loop 2110 / Segment LQ02) are described below.
ISA Interchange Control Header
4
Required
Ref # ID
ISA01 101
Name
Authorization Number
Req
Y
ISA02 102
Code set Summary
Y
ISA03 103
Y
ISA04 104
Security information
Qualifier
Security information
ISA05 105
Interchange ID Qualifier
Y
ISA06 106
ISA07 105
Interchange Sender ID
Interchange ID Qualifier
Y
Y
ISA08 107
Interchange Receiver ID
Y
ISA09 108
ISA10 I09
ISA11 I65
Interchange Date
Interchange Time
Repitition Seperator
Y
Y
Y
Interchange Control
Version Number
ISA13 I12
Interchange Control
Number
ISA14 I13
Acknowledgment
Requested
ISA15 I14
Interchange Usage
Indicator
ISA16 I15
Component Element
Seperator
Element Separator *
Y
ISA12 111
Y
Y
Y
Y
Y
Codes
00
Notes
Code identifying type of
information in the
Authorization element
0000000000 Information used for additional
identification
00
Information needed Security
Information
Blank
Information that acts as
Security
30
The number used to identify the
sender or receiver
Federal Tax id of the sender
30
Code indicating the sgtructure
requirement to identify the
sender or receiver ID element.
820344294 Information sent by the user to
identify the sender as their
sender ID
YYMMDD Date the interchange was sent
HHMM
The time the file was created
^
The separators identify data
within elements.
00501
Code used to indentify the
version submitted
Unique number identified by
the sender
0
A code sent by the submitter
requesting acknowledgememt
P, T
Code indicating Test or
Production
>
Delimiter seperator
Terminator Delimiter ~
GS Functional Group Header
5
Required
Ref #
GS01
ID
479
Name
Functional Identifier
Code
Req
Y
GS02
142
Application Senders
Code
Y
GS03
124
Application Receivers
Code
Y
GS04
GS05
GS06
373
337
28
Y
Y
Y
GS07
455
GS08
480
Group Date
Group Time
Group Control Number
(must match GE02)
Responsible Agency
Code
Version/Release Code
Codes
BE
Y
X
Y
005010X220A1
Notes
Code identifying the
application related transaction
sets
Federal Tax id of the Sender
(Can also be another code
identified by the sender)
Code identifying receiving
transmission (code must be
agreed upon by sender and
receiver)
CCYYMMDD
HHMMSSDD
Unique Number created by
Sender
Code identified by the
standard
ST Transaction Set Header
Required
Ref #
ST01
ID
143
ST02
329
ST03
1705
Name
Transaction Set
Identifier
Transaction Set Control
Number
Implementation
Convention Reference
Req
Y
Y
Y
Codes
834
Notes
Code identifying Transaction
Set
Unique Number that must be
unique to each transaction
005010X220A1 Reference assigned to
Identify Implementation
Convention
BGN Beginning Segment
Required
6
Ref #
ID
BGN01 353
Req.
Y
Codes
00
Notes
00=Original
BGN02 127
Name
Transaction Set Purpose
Code
Reference Identification
Y
1
BGN03 373
BGN04 337
BGN05 623
Date
Time
Time Code
Y
X
O
MT
BGN06 127
Reference Identification
O
Blank
O
2, 4
Reference information for a
particular Transaction Set
Date=YYMMDD
24 hour clock HHMM
Code for Time in accordance
with International Standards
Reference information for a
particular Transaction Set
2=Change(update), 4=Verify
BGN08 306
Action Code
If BN05 is present then BN is required
REF Transaction Set Policy Number
Situational
Ref #
ID
REF01 128
Name
Code qualifying the
Reference Qualifier
REF02 127
Reference Identification
Either REF02 or REF03 is required
Req.
Y
X
Codes
38
Notes
Reference Identification
Master Policy Number
DTP File Effective Date
Situational
7
Ref #
ID
DTP01 374
Name
Date/Time Qualifier
Req.
Y
DTP02 1250
Date Time Qualifier
Y
DTP03 1251
Date Time Period
Y
Codes
007
Notes
Code indicating date or time or
both
D8
Code indicating date, time or
date and time format
CCYYMMDD
CCYYMDD Actual date, time or range of
dates, times or dates and times.
QTY Transaction Set Control Totals
Situational
Ref #
ID
QTY01 673
Name
Quantity Qualifier
Req.
Y
QTY02 380
Quantity
X
Codes
DT, ET, TO
Notes
Code specifying the type of
quantity.
DT = Dependent Total
ET = Employee Total
TO = Total
Numeric value of quantity
Loop 1000A
N1 Sponsor Name
Required
Ref #
N101
ID
98
Name
Entity Identifier Code
Req.
Y
Codes
P5
N102
N103
93
66
Name
Code Qualifier
Y
Y
FI
N104 67
Identification Code
At least one of N102 or N103 is required
Y
Notes
Code identifying a physical
location, property of individual
Sender Client Name
Code Identifying the method of
code structure
Federal Tax id of the Plan
Loop 1000B
N1 Payer
Required
8
Ref #
N101
ID
98
Name
Entity Identifier Code
Req.
Y
N102
93
Name
Y
N103
66
N104
67
Identification Code
Qualifier
Identification Code
X
Codes
IN
Notes
Organizational entity, physical
location, property or individual
Should contain Blue Cross of
Idaho
FI
Code for system method of code
structure
820344294 Code identifying party or other
code
At least one of NM102 or NM103 is required.
If N103 or N104 is present then the other is also required.
Loop 1000C
N1 TPA/Broker Name
Ref #
N101
ID
98
Name
Entity Identifier Code
Req.
Y
N102
93
Name
Y
N103
66
Code Qualifier
X
N104
67
Identification code
X
Codes
BO,
TV
Notes
Code identifying an organizational
entity, property or physical
location
Name
94, FI,
XV
Code for structure
Actual code
At least N102 or N103 is required.
If either N103 or N104 is present then the other is required.
Loop 1100C
ACT TPA/Broker Account Information
Situational
Ref #
ID
Name
Req.
Codes
Notes
9
ACT01 508
Account Number
Y
Account number Assigned
ACT06 508
Account Number
X
Account number Assigned
If ACT03 or ACT04 are present then the other is required.
If ACT05 is present then ACT06 is required.
If ACT07 is present then ACT05 is required.
ACT02 is the name of the account in ACT01. ACT07 is the same name as ACT06
Loop 2000
INS Member Level Detail
Required
Ref #
INS01
ID
1073
Name
Yes/No Condition
Req.
Y
Codes
Y, N
Notes
Yes or No Indicator
10
INS02
1069
Individual Relationship
Code
Y
01,18, 19
INS03
875
Maintenance Type
Code
O
001, 021, 030
INS04
1203
Maintenance Reason
Code
O
XN
INS05
1216
Benefit Status Code
O
A, C, S, T
INS06
C052
Medicare Status Code
O
Blank, D, E
INS06- 1218
01
Medicare Plan Code
O
INS06- 1701
02
INS07 1219
Eligibity Reason Code
O
Consolidated Omnibus
Budget
Employment Status
Code
Student Status Code
O
Blank
O
FT, PT, RT
INS08
584
Y=insured is subscriber.
N=insured is a dependent
01=Spouse, 18=Self,
19=Child (See Guide for
complete list)
001=Change, 030=Audit or
Compare (030 should always
be used for full files)
Codes to identify
maintenance change entities
(see Guide for complete list)
Actual code identifying
Status change
Identifies Medicare coverage
and associated reason for
Medicare Eligibility.
D=Medicare, E=No Medicare
Code identifying Medicare
Plan Required when INS06 is
used
Reason for Eligibility
This field should be blank
Code displaying employment
status of claiment
INS09 1220
O
F, N, P
Code displaying student
status of a patient if 19 or
older, not handicapped and
not insured
INS10 1073 Condition Response
Y/N
Code indicating a Yes or No
code
response. Y=Handicapped,
N=not handicapped
INS11 1250 Date Time period
X
D8
Indicates date to follow in
Qualifier
CCYYMMDD format
INS12 1151 Date Time Period
X
CCYYMMDD Actual Date in above format,
Date of Death
INS13 1165 Confidentiality Code
O
Not Used
INS17 1470 Number
O
Generic Number if family
members have the same
birthdate (For dependents)
If either INS11 or INS12 is present, the other is required.
11
REF Subscriber Identifier
Required
Ref #
ID
REF01 128
Name
Reference Identification
Qualifier
REF02 127
Reference Identification
Either REF02 or REF03 is required
Req.
Y
Codes
OF
Notes
Reference Identification for
Subscriber number
Social Security Number
Codes
IL
Notes
Reference Code
X
REF Member Policy Number
Situational
Ref #
ID
REF01 128
REF02 127
Name
Reference Identifcation
Qualifier
Reference Identification
Req.
Y
X
BCI supplied Group Number.
This number references a specific
transaction set.
Either REF02 or REF03 is required
REF Member Supplemental Identifier
Situational
Ref #
REF
ID
128
REF02 127
Name
Reference Identification
Qualifier
Reference Identification
Req.
Y
X
Codes
23
Notes
23=Client Number
Employee Id
12
REF04
NOT USED
Either REF02 or REF03 is required
Situational
Ref #
REF
ID
128
Name
Reference Identification
Qualifier
REF02 127
Reference Identification
REF04
NOT USED
Either REF02 or REF03 is required
Req.
Y
Codes
DX
X
Notes
DX=Department/Agency Number
BCI supplied Sub Group Number
Situational
Ref #
REF
ID
128
REF02 127
Name
Reference Identification
Qualifier
Reference Identification
Req.
Y
Codes
17
X
Notes
17=Client Reporting Category
BCI supplied Class Code or
Benefit Level Code
REF04
NOT USED
Either REF02 or REF03 is required
DTP Member Level Dates
Situational
Ref #
ID
DTP01 374
Name
Date Time Qualifier
Req.
Y
DTP02 1250
Date Time Period
Qualifier
Y
Codes
336,
337
D8
Notes
336=Employment
Begin337=Employment Ends
D8=Date in format CCYYMMDD
13
DTP03 1251
Date Time Period
Y
DTP02 is the date or time period that will populate in DTP03
Begin / End Date of Employment
Situational
Ref #
ID
DTP01 374
Name
Date Time Qualifier
Req.
Y
DTP02 1250
Date Time Period
Qualifier
Date Time Period
Y
DTP03 1251
Codes
336,
337
D8
Y
Notes
356=EligibilityBegin
357=Eligibility End
D8=Date in format CCYYMMDD
Actual Begin / End Date of
Eligibility
DTP02 is the date or time period that will populate in DTP03
14
Loop 2100A
NM1 Member Name
Required
Ref #
NM101
NM102
NM103
ID
98
1065
1035
NM104
NM105
NM106
NM107
NM108
1036
1037
1038
1039
66
Name
Element Name
Entity Type Qualifier
Last Name or Org Name
Req.
Y
Y
X
Codes
IL
1
Name, First
O
Name, Middle
O
Name Prefix
O
Name Suffix
O
Identification Code
X
34
Qualifier
NM109 67
Identification Code
X
If either NM108 or NM109 is present then the other is required.
Notes
IL=Subscriber
Person
Last name or Organizational
Name
First Name
Middle Name or Initial
Prefix to Name
Suffix to Name
Number Indicating the type of
number following
Social Security Number
PER Member Communications Numbers
Situational
Ref #
ID
PER01 366
PER03 365
PER04 364
Name
Contact Function Code
Communication Number
Qualifier
Communication Number
Req.
Y
X
Codes
IP
HP,
TE
X
PER05 365
Notes
IP=Insured Party
TE=Telephone, HP= Home Phone
Actual number from qualifier
above. Phone number
EM=Email
Communication Number
X
EM
Qualifier
PER06 364
Communication Number
X
Email address
PER07 365
Communication Number
X
Blank
Qualifier
PR08
364
Communication Number
X
Blank
If either PER03 or PER04 is present then the other is required.
If either PER05 or PER06 is present then the other is required.
If either PER07 or PER08 is present then the other is required.
15
N3 Member Residence Street Address
Situational
Ref #
N301
N302
ID
166
166
Name
Address Information
Address Information
Req.
Y
O
Codes
Notes
Address Line 1
Address Line 2
N4 Member City, State, and Zip Code
Required
Ref # ID
Name
N401 19
City Name
N402 156
State or Providence Code
N403 1126
Postal Code
N404 26
Country Code
N405 309
Location Qualifier
N406 310
Location Identifier
N407 1715
Country Subdivision Code
Only N402 or N407 may be present
Req.
O
X
X
X
X
O
X
Codes
Notes
City name (free form)
State
Postal Code
Country Code
Leave Blank
Leave Blank
Leave Blank
If either N406 or N405 is present the other is required
If N407 is present then N404 is required.
16
DMG Member Demographics
Situational
Ref #
DMG01
ID
1250
DMG02
DMG03
DMG04
1251
1068
1067
DMG05
C056
DMG05- 1109
01
DMG05- 1270
02
DMG05- 1271
03
DMG06 1066
Name
Date and Time period
Format Qualifier
Date Time Period
Gender Code
Marital Status
Req.
X
Composite Race or
Ethnicity Information
Race or Ethnicity Code
X
O
7, 8,
A, B,
C, D,
E, F,
G, H,
I, J, N,
O, P,
Z
Code List Qualifier Code
X
RET
Industry Code
X
Citizen Status code
X
X
O
O
Codes
D8
F,M
I, M,
B
Notes
Date Qualifier
Actual Date of Birth
Female, Male
I=Single, M=Married,
B=Registered Domestic Partner
See Guide for additional codes.
Blank
7=Not Provided, 8=Not
applicable, A=Asiom or Pacific
Islander, B= Black,
C=Caucasion, D=Subcontinent
Asian American, E=Other Race,
F=Asain Pacific America,
g=Native American, H=Hispanic,
N=Black (Non Hispanic),
O=White (Non Hispanic),
P=Pacific Islander, Z=Mutually
defined
Classification of Race or
Ethinicity
Please leave Blank
1, 2, 3, Please leave blank
4, 5, 6,
7
DMG10 1270
Code List Qualifier code X
REC
Please leave Blank
DMG11 1271
Industry Code
X
Code from a specific industry
code list
If either DMG01 or DMG02 is present then the other is required
If either DMG10 or DMG11 is present then the other is required.
If DMG11 is present then DMG05 is required.
17
Loop 2300
HD Health Coverage
Situational
Ref #
HD01
ID
875
Name
Maintenance Type Code
Req.
Y
Codes
001, 021,
024, 030
HD03
1205
Insurance Line code
O
MM,
DEN,
EPO,
HMO,
VIS
HD04
1204
O
HD05
1207
Plan Coverage
Description
Coverage Level Code
O
CHD,
DEP, E1D,
E2D, E3D,
E5D, E6D,
E7D, E8D,
E9D,
ECH,EMP,
ESP,
FAM,
IND, SPC,
SPO,
TWO
Notes
001=Change, 021=Addition,
024=Cancellation or
Termination, 030=Audit or
Compare
MM=Major Medical, UR=
Utilization Review,
DEN=Dental, EPO=Exclusie
Provider Org. HMO=Health
Maintenance Org,
VIS=Vision
Plan Code
CHD=Children Only,
DEP=Dependents only,
E1D=Employee and One
dependent, E2D=Employee and
two dependents, E3D=Employee
and three dependents,
E5D=Employee and One or
More Dependents,
E6D=Employee and Two or
More Dependents,
E7D=Employee and Three or
More Dependents ,
E8D=Employee and Four or
more Dependents,
E9D=Employee and Five or
more Dependents,
ECH=employee and children
EMP=Employee only
ESP=Employee and Spouse,
FAM=Family, IND Individual,
SPC=Spouse and Children,
SPO=Spouse Only, TWO=Two
Party
18
DTP Health Coverage Dates
Required
Ref #
ID
DTP01 374
Name
Date Time Qualifier
Req.
Y
DTP02 1250
Codes
303,
348,
349
D8
Date Time Period
Y
Qualifier
DTP03 1251
Date Time Period
Y
DTP02 is the date or time period that will populate in DTP03
Notes
303=Maintenance Effective,
348=Benefit Begin 349=Benefit
Date Qualifier
Actual Date
REF Health Coverage Policy Number
Situational
Ref #
ID
REF01 128
REF02 127
Name
Reference Id Qualifier
Reference Identification
Req.
Y
X
Codes
IL
Notes
IL=Group or Policy Number,
Reference Information for a
specific Transaction Set. May
contain 12345678 if Group or
Policy number is not available
Codes
1
Notes
Number assigned to separate
within transaction sets. Should
contain “1”
At least one or the other REF02 or REF03 is required.
Loop 2310
LX Provider Information
Situational
Ref #
LX01
ID
554
Name
Assigned Number
Req.
Y
19
FSA Flexible Spending Account
Situational
Ref #
ID
FSA01 875
Name
Maintenance Type Code
Req.
Y
FSA02 1202
O
FSA03 1203
Flexible Spending
Account Selection Code
Reason Code
FSA04 508
FSA05 594
Account Number
Frequency Code
O
O
FSA06 1204
O
FSA07 1161
Plan Coverage
Description
Product Option Code
FSA08 1161
FSA09 1161
Product Option Code
Product Option Code
O
O
O
O
Codes
001,021,
024, 030
D, H
Notes
Code identifying type of item
maintenance
D=Dependent Care,
H=Healthcare
36
36=Contribution or Plan
Allocation
Account number assigned
1, 2,3, 4, 1=Weekly, 2=Biweekly,
5, 6, 7,
3=Semimonthly, 4=Monthly,
8, 9, B, 5=Other, 6=Daily, 7=Annual,
C, H, Q, 8=Two Calendar Months,
X, U, Z 9=Lump-Sum Separation
Allowance, B=Year to Date,
C=Single, H=Hourly,
Q=Quarterly, S=Semiannual,
U=Unknown, Z=Mutually
Defined
Plan or coverage description
1,2, 3, 4,
5, 6, 7,
8, 9, A,
B, C, D,
N, O, S,
10, 11,
12, 13,
14, 15,
28, 29
1=Pretax, 2=Post-tax,
3=Qualified, 4=Non Qualified,
5=401K, 6=Individual
Retirement Account, 7=Keogh,
8=Simplified Employee Pension,
9=Single Premium, A=First to
Die, B=Last to Die, C=Child
Rider, D=discontinue one Bill
Submission, N=Benefit
Continuation, O=One bill
Submission, S=Salary
Continuation, 10=Flexible
premium, 11=Variable Premium,
12=Fixed Premium,
13=Registered under the Income
Tax Act of Canada, 14=Non
Registered und the Income Tax
Act of Canada, 15=registered
Spousal case, 28=Exclusive,
29=Shopped
Not Required
Not Required
20
FSA04 is the flexible spending account policy number.
FSA05 specifies the frequency of contribution.
AMT Monetary Amount Information
Situational
Ref #
AMT01
AMT02
AMT03
ID
522
782
478
Name
Amount Qualifier Code
Monetary Amount
Credit/Debit Flag Code
Req.
Y
Y
O
Codes
1
Codes
390,
391
D8
C, D
Notes
Code to qualify amount
Actual Monetary Amount
Code indicating if it is a credit or
debit
DTP Date or Time or Period
Situational
Ref #
ID
DTP01 374
Name
Date/Time Qualifier
Req.
Y
DTP02 1250
Date Time Period Format
Qualifier
Date Time Period
Y
DTP03 1251
Y
Notes
290=Payroll Begin, 391=Payroll
End
Date Qualifier
Actual Date
SE Transaction Set Trailer
21
Required
Ref #
SE01
ID
96
Name
Number of Included
Segments
Req.
Y
SE02
329
Transaction Set Control
Number
Y
Codes
Notes
Total number of Segments
included in the transaction set
including ST and SE segments
Control number that must be
unique within the transaction set
functional group and must be
assigned by the Originator for a
transaction set
GE Functional Group Trailer
Required
Ref #
GE01
ID
97
Name
Number of Transaction
Sets Included
Req.
Y
Codes
Notes
Total number of transaction sets
included in the functional group
or interchange
GE02
28
Group Control Number
Y
Assigned number originated and
maintained by the sender
The data interchange control number in GE02 must be identical to the same data element in the
associated functional group header GS06.
IEA Interchange Control Trailer
Required
Ref #
IEA01
ID
116
Name
Number of Included
Functional Groups
Req.
Y
IEA02
112
Interchange Control
Number
Y
Codes
Notes
A count of the number of
functional groups included in an
interchange
A control number assigned by the
Interchange sender
22