PacifiCare Electronic Data Interchange
834 Transaction Companion Guide
Health Care Benefit
Enrollment and
Maintenance
(Version 1.0 – October 2003)
834
ANSI ASC X12 834 (004010X095 & 004010X095A1)
PacifiCare Health Systems – 834 Transaction Companion Guide
Table of Contents
INTRODUCTION ....................................................................................................................... 3
INTENT AND SCOPE OF THE HEATH CARE BENEFIT ENROLLMENT AND
MAINTENANCE TRANSACTION .............................................................................................. 4
ASSUMPTIONS......................................................................................................................... 4
PREFERENCES AND CONVENTIONS..................................................................................... 5
General File Submission Requirements ...............................................................................................................5
Causes for Rejection of File Submission ..............................................................................................................6
Field Lengths and Values ......................................................................................................................................6
COMMUNICATION METHODS SUPPORTED .......................................................................... 6
Third-Party Administrators..................................................................................................................................7
Direct Submission ..................................................................................................................................................7
PRIVACY AND SECURITY PROTECTION ............................................................................... 7
ENCRYPTION REQUIREMENTS .............................................................................................. 7
HANDLING ACKNOWLEDGEMENTS ...................................................................................... 7
ANSI ASC X12 Acknowledgements .....................................................................................................................7
SPECIFIC USAGE ..................................................................................................................... 8
ERROR HANDLING .................................................................................................................. 9
APPENDIX A – SAMPLE FILES ..............................................................................................10
APPENDIX B – TESTING REQUIREMENTS ...........................................................................14
COMBINED 834 TRANSACTION SET – 004010X095 & 004010X095A1 ................................15
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Introduction
PacifiCare is publishing this Electronic Data Interchange (EDI) 834 Transaction Companion
Guide (Companion Guide) to accompany the ASC X12N Combined Implementation Guide
(Implementation Guide) for the ASC X12N Health Care Benefit Enrollment and Maintenance
(834) (004010X095 & 004010X095A1) transaction set.
The primary purpose of this Companion Guide is to minimize the variability in the transaction
set that is exchanged within all of the regions of PacifiCare. The Companion Guide will
document assumptions, conventions, and preferences that PacifiCare expects employer groups,
Third-Party Administrators, and information system vendors to comply with.
Additionally, the Companion Guide will help to walk organizations through the implementation
process so that the resulting transaction will meet the following business objectives:
1. Convey all required business information: The transaction will convey the
comprehensive set of information that is required for health plans to conduct their
business.
2. Interpret information in the same way: The definition of the transaction will be specific
so that Trading Partners can correctly interpret the information that is received from each
other from a business perspective.
3. Simplify the communication: The transaction will be standard to simplify communication
between Trading Partners as well as comply with Health Insurance Portability and
Accountability Act (HIPAA) regulations.
The underlying premise of the PacifiCare Companion Guide is that it defines the superset of
business functionality for the Health Care Benefit Enrollment and Maintenance (834)
Transaction Set. The Implementation Guide provides general information about EDI
transmission, such as delimiters, enveloping, and related topics. PacifiCare’s Companion Guide
will not duplicate these efforts.
In order to establish a simplified implementation environment, the Companion Guide describes a
set of assumptions and conventions that will be followed by Trading Partners as they implement
the 834 transaction and interpret the information that is contained within it. These conventions
provide additional clarity about data structures and data elements (i.e., what they mean), and
describe how these data elements relate to information contained in the information systems
belonging to each Trading Partner (i.e., how they will be used).
It should be noted that the Companion Guide does not add, delete, or change the name of any
data element or segment nor change the meaning or intent of any implementation specification
that is specified in the Implementation Guide. HIPAA Implementation Guides are available
through Washington Publishing, Inc. at:
http://www.wpc-edi.com/
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Intent and Scope of the Heath Care Benefit Enrollment and
Maintenance Transaction
The Health Care Benefit Enrollment and Maintenance (834) transaction set will be used to report
an employer group’s member eligibility. The intent of this transaction is to process the
following:

Subscriber and dependent enrollment adds.

Subscriber and dependent terminations.

Subscriber and dependent eligibility changes.

Subscriber and dependent demographic changes.
The information provided in the transaction will reflect the status of the member with the
employer group at the point in time the submission is sent. The intent of this transaction is to
maintain member eligibility and demographic information.
Assumptions
The following assumptions are being made for purposes of this guide:

The Interchange Transmission refers to an ISA/IEA.

The Functional Group refers to the GS/GE.

The Transaction Set refers to the ST/SE (can come in multiple functional groups).

Employer Groups or Third-Party Administrators submitting the 834 Health Care Benefit
Enrollment and Maintenance transaction directly to PacifiCare must first be registered.
Registration includes the exchange of important information necessary for successful
e-Commerce, including submitter and receiver information, connectivity specifications,
etc. For most questions relating to information in this Companion Guide, contact the
PacifiCare Enterprise EDI Services (EES) department at:

Email:
EDISupport@phs.com
Fax:
1-972-866-1690 Attn: EDI Support
Telephone:
1-800-203-7729
For more information on whether an employer group or Third-Party Administrator acting
on behalf of the employer group needs to submit enrollment data in compliance with the
834 transaction standard, please consult counsel or refer to the U.S. Department of
Health and Human Services website at:
http://aspe.os.dhhs.gov/admnsimp/pl104191.htm#261

For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare
representative.
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
834 Health Care Benefit Enrollment and Maintenance transactions submitted to
PacifiCare are assumed to be production-ready. The employer groups, Third-Party
Administrators, and system vendor(s) will have completed testing prior to submission to
ensure HIPAA compliance.
Preferences and Conventions
The items listed below outline specific preferences and conventions to be used when transmitting
data to PacifiCare.
General File Submission Requirements
1. Trading Partner Agreements specify the terms and conditions by which transactions are
exchanged electronically with PacifiCare. This Companion Guide may be an addendum
to a new or existing Trading Partner Agreement or other Business Agreement.
2. PacifiCare strongly recommends that every Trading Partner submitting the 834 Health
Care Benefit Enrollment and Maintenance transaction directly to PacifiCare sign a
Trading Partner Agreement.
3. PacifiCare strongly recommends that employer groups or Third-Party Administrators
representing the employer group obtain certification from an approved Third-Party
Certification System and Service (TPCSS), stipulating that its transactions are HIPAA
compliant. For more information about certification and certification vendors, speak to
the appropriate EES Project Manager.
4. While PacifiCare supports all of the characters in the extended character set, it is
recommended that incoming 834 data use the basic character set as defined in Appendix A
of the Implementation Guide.
5. The subscriber hierarchical level (HL segment) must be in order from one, in increments
of one (+1), and must be numeric.
6. Some of the segments and data elements labeled as “Not Used” in this Companion
Guide, but labeled as “Situational” in the Implementation Guide, may still be accepted
and validated to ensure HIPAA compliance. However, PacifiCare will not actually
process these segments and data elements.
7. Data submitted to PacifiCare in ANSI HIPAA standard format may be translated into a
proprietary format for purposes of internal processing.
8. Only multiple data loops or segments should be populated with the first occurrence, and
each loop or segment populated consecutively thereafter. There should be no loops or
segments without data.
9. PacifiCare suggests retrieval of the ANSI 997 functional acknowledgment files on or
before the first business day after the file is submitted, but no later than five business
days after the file submission. Beginning with the fifth business day after submission, it
will no longer be available.
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10. Encryption and compression of files using PGP v2.6 or later is supported for
transmissions between the submitter and PacifiCare.
11. PacifiCare prefers to receive only one transaction type (records group) per interchange
(transmission). A submitter should only submit one GS-GE (Functional Group) within
an ISA-IEA (Interchange).
12. Trading Partners cannot send test and production information within the same
transaction file, regardless of the transaction. Test data and production data must be
submitted in separate files. Notify your EES Project Manager regarding submission of
test data.
13. As of the release of this document (October 2003), PacifiCare accepts the following
versions of the Implementation Guide, and any future versions as specified by the
regulation:

ANSI ASC X12N 834 (004010X095 & 004010X095A1)
Causes for Rejection of File Submission
1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be
used as long as the same one is used throughout the transaction. Printable characters are
preferred. A carriage return/linefeed will cause an interchange/transmission to be rejected.
2. Only loops, segments, and data elements valid for the Implementation Guide will be
translated. Submission of data that is not valid based on the Implementation Guide will cause
files to be rejected.
3. If a segment or data element within a segment is specified in the Implementation Guide as
“Not Used,” yet is present in the transaction, it will be rejected as an error.
4. PacifiCare will reject an interchange transmission that is submitted with a submitter
identification number in either ISA06 (Sender ID) or GS02 (Application Sender’s Code) that
is not registered for electronic claims submission.
5. PacifiCare will reject a functional group or interchange transmission that is submitted with an
invalid value in either ISA08 (Receiver ID) and/or GS03 (Application Receiver’s Code),
based on the Trading Partner agreement.
6. PacifiCare will reject an interchange transmission that is not submitted with unique values in
the ST02 (Transaction Set Control Number) or GS06 (Group Control Number) elements
within the interchange transmission.
Field Lengths and Values
Although the 834 transaction allocates two street address elements of 55 characters each, the
internal PacifiCare system’s street address is a maximum of 30 characters. Using extended
length addresses may cause errors in employee mailings.
Communication Methods Supported
PacifiCare supports the following communication methods:
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Third-Party Administrators
For employer groups’ EDI enrollment requests, please contact the Third-Party Administors
directly. They will provide all the necessary testing and submission information required.
Direct Submission
For direct submission to PacifiCare or for details regarding communication protocols, contact the
PacifiCare EES department at:
Email:
EDISupport@phs.com
Fax:
1-972-866-1690 Attn: EDI Support
Telephone:
1-800-203-7729
Privacy and Security Protection
PacifiCare will comply with the privacy and confidentiality requirements as outlined in the
HIPAA Privacy and Security regulations regarding the need to protect health information. All
Trading Partners are also expected to comply with these regulations.
Encryption Requirements
PacifiCare will comply with the data encryption policy as outlined in the HIPAA Privacy and
Security regulations regarding the need to encrypt health information and other confidential data.
All data within a transaction that is included in the HIPAA definition of Electronic Protected
Health Information (ePHI) will be subject to the HIPAA Privacy and Security regulations and
PacifiCare will adhere to such regulations and the associated encryption rules. All Trading
Partners are also expected to comply with these regulations and encryption policies.
Handling Acknowledgements
ANSI ASC X12 Acknowledgements
PacifiCare utilizes two forms of acknowledgements: the TA1 Interchange Acknowledgement and
the 997 Acknowledgement. Therefore, the Trading Partner can, at its discretion, request that we
send:

a TA1 acknowledgment

a 997 acknowledgement

both acknowledgements or

no acknowledgement at all.

For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare
representative.
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It should be noted that at minimum, in the case of an error, PacifiCare will automatically
generate a negative TA1 acknowledgement, even if the Trading Partner has requested that
acknowledgements not be sent.
TA1 Interchange Acknowledgment
A TA1 acknowledgment will be generated and returned to the Trading Partner to indicate the
success or failure of processing a transaction from the ISA to the IEA. It will indicate whether or
not there were errors at the ISA or envelope level.
997 Functional Acknowledgment
The 997 Functional Acknowledgement will be sent back to the Trading Partner as determined by
Trading Partner setup to indicate the success or failure of 834 compliance validation within each
GS/GE segment.
PacifiCare will return 004010 as the version in GS08 (Version/Release/Industry Identifier Code)
of the 997.
Specific Usage
Following is the structure for passing the PacifiCare Group Numbers and Plan Codes.
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REF
Pos: 290
Max: 5
Detail – Optional
Loop: 2300
Elements: 2
Reference Identification
To specify identifying information
Element Summary:
Ref
REF01
Id
Element Name
128 Reference Identification Qualifier
Description: Code qualifying the Reference Identification
Req
Type
Min/Max
M
ID
2/3
Must use
Usage
C
AN
1/30
Used
User Note 1: There are many iterations of the REF segment at
this position in the 834.
1L Group or Policy Number
ZZ Mutually Defined
REF02
127 Reference Identification
Description: Reference information as defined for a particular
Transaction Set or as specified by the Reference Identification
Qualifier
The Reference ID Qualifier value of 1L Group or Policy
number will indicate the passing of the Group Number.
REF*1L*12345678 5-8 digit number supplied by PacifiCare.
HMO group numbers are either 5 or 6 digits long. The PPO
group numbers are 8 digits long.
The Reference ID Qualifier value of ZZ Group or Policy
number will indicate the passing of the Plan Code.
REF*ZZ*UUU 3-5 digits code supplied by PacifiCare. There may
be an exception for PPO plan code.
Error Handling
If HIPAA standard validation errors are encountered, the file will be rejected and no individual
employee transactions will be processed.
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Appendix A – Sample Files
Business Scenario 1
Enroll an Employee in Multiple Health Care Insurance Products
John Doe is enrolling in three health care products – health, dental, and vision. He also has Coordination
of Benefits (COB) with another insurance company.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
N1*IN*ABC INSURANCE CO~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*22*12345~
Business Scenario 2
Add a Dependent (Full-time Student) to an Existing Contract
James E. Doe, the son of John Doe, is being enrolled under John Doe’s medical coverage. James is
enrolled at Penn State and expects to graduate on 5/15/1998. His Social Security Number is 103229876.
The enrollment for the subscriber, John Doe, had to be submitted before his dependents can be enrolled.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*021*28*A****F~
REF*0F*123456789~
REF*1L*123456001~
DTP*351*D8*19980515~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
NM1*M8*2*PENN STATE UNIVERSITY~
HD*021*HLT~
DTP*348*D8*19960601~
SE*15*12345~
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Business Scenario 3
Enroll an Employee in a Managed Care Product
William Smith is enrolling in the HMO product effective 6/1/1996. He has selected Dr. Bernard Brown as
his primary care physician for the program. Mr. Smith is already Dr. Brown’s patient; therefore, the
primary care information code value is 01. Dr. Brown’s provider number is 143766.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*202443307~
REF*1L*123456001~
DTP*356*D8*19960112~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
PER*IP**HP*7172343334*WP*7172341240~
N3*1715 SOUTHWIND AVENUE~
N4*ANYTOWN*PA*171110000~
DMG*D8*19700614~
HD*021**HMO~
DTP*348*D8*19960601~
LX*01~
NM1*P3*1*BROWN*BERNARD**DR****25~
SE*18*12345~
Business Scenario 4
Add Subscriber Coverage
William Smith is adding dental coverage to his contract, which will be effective on 7/1/1996.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001*22*A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*2024433307~
HD*021**DEN~
DTP*348*D8*19960701~
SE*12*12345~
NOTE: In the previous example, to remove coverage do the following: change the maintenance type code
(HD01) from 021 (addition) to 024 (cancellation/termination), and change the date/time qualifier
(DTP01) from 348 (benefit begin) to 349 (benefit end).
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Business Scenario 5
Change Subscriber Information
John Doe is correcting his date of birth.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
N1*P5*GENERIC INC~
N1*IN*ABC INSURANCE*FI*654456654~
INS*Y*18*001*25*A***FT~
REF*0F*123456789~
REF*1L*123456001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19500415*M~
NM1*70*1*DOE*JAMES*E~
DMG*D8*19500416*M~
SE*12*12345~
Business Scenario 6
Cancel a Dependent
John Doe is canceling coverage for his over-age dependent, James, to be effective 8/1/1996.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*024*07*A~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19960801~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
SE*12*12345~
Business Scenario 7
Terminate Eligibility for a Subscriber
The eligibility for John Doe is being canceled because he terminated employment on 10/1/1996.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*024*08*A***TE~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19961001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
SE*10*12345~
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Business Scenario 8
Reinstate an Employee
John Doe’s contract was incorrectly canceled and is being reinstated.
ST*834*12345~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*303*D8*19961001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
SE*11*12345~
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Appendix B – Testing Requirements
Testing Requirements
EDI Trading Partner Testing
PacifiCare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National
Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of testing that
need to occur in order to remain in line with the health care industry’s testing recommendations. Initially,
the types of testing that PacifiCare strongly recommends for the 834 Transaction Set includes:
 Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments, segment order,
element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP
syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity
of the EDI submission.
 Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation Guidespecific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes,
elements and segments. Also included in this type is testing for HIPAA required or intra-segment
situational data elements, testing for non-medical code sets as laid out in the Implementation Guide,
and values and codes noted in the Implementation Guide via an X12 code list or table.
Third-Party Certification Systems and Services (TPCSS)
TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their
HIPAA transactions. PacifiCare requests that Trading Partners test with a TPCSS and provide evidence
of such testing. EDI submitters that have tested their 834 Transaction Set with a certification system may
provide a certificate of compliance. The certificate should specify the different types of testing passed or
provide us with a certification website that indicates you have successfully passed certain types of
certification testing.
PacifiCare will collect evidence of the Third-Party Certification during the Trading Partner Setup process.
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Combined 834 Transaction Set – 004010X095 & 004010X095A1
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Use
Page
B.3
ISA01
R
R
Authorization Information
Security Information Qualifier
ISA02
ISA03
R
R
Security Information
Interchange ID Qualifier
ISA04
ISA05
R
R
Interchange Sender ID
ISA06
R
Interchange ID Qualifier
ISA07
R
Interchange Receiver ID
Interchange Date
Interchange Time
Interchange Control Standards Identifier
ISA08
ISA09
ISA10
ISA11
R
R
R
R
Interchange Control Version Number
ISA12
R
Interchange Control Number
ISA13
R
Acknowledgment Requested
ISA14
R
Usage Indicator
ISA15
R
Component Element Separator
ISA16
R
ISA - Interchange Control Header
Authorization Information Qualifier
GS - Functional Group Header
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Element
R
Possible Values
Description/Preferred Usage
00 - No Authorization Information Present (No
Meaningful Information in I02)
03 - Additional Data Identification
B.4 00 - No security information present (No
Meaningful Information in I04)
01 - Password
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
This ID qualifies the Sender in ISA06.
Preferred Value:
01
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
This ID qualifies the Receiver in ISA08.
Preferred Value:
34698723
B.5
YYMMDD
HHMM
U - U.S. EDI Community of ASC X12, TDCC,
and UCS
00401 - Draft Standards for Trial Use Approved
for Publication by ASC X12 Procedures Review
Board through October 1997
The interchange Control Number, ISA13, must be identical to
the associated Interchange Trailer IEA02.
B.6 0 - No Acknowledgment Requested
1 - Interchange Acknowledgment Requested
P - Production Data
T - Test Data
This is the delimiter used to separate component data
elements within a composite data structure.
B.8
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Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Description/Preferred Usage
Functional Identifier Code
GS01
R
Application Sender’s Code
GS02
R
Use this code to identify the unit sending the information.
Application Receiver’s Code
GS03
R
Use this code to identify the unit receiving the information.
Preferred Value:
34698723
Date
GS04
R
Time
Group Control Number
Responsible Agency Code
Version/Release/Industry Identifier Code
GS05
GS06
GS07
GS08
R
R
R
R
ST - Transaction Set Header
Transaction Set Identifier Code
Transaction Set Control Number
ST01
ST02
R
R
R
27
27
27
BGN - Beginning Segment
Transaction Set Purpose Code
BGN01
R
R
28
28
Transaction Set Identifier Code
BGN02
R
29
Transaction Set Creation Date
BGN03
R
29
CCYYMMDD
Transaction Set Creation Time
BGN04
R
29
HHMM
Time Zone Code
BGN05
S
29
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Transaction Set Identifier Code
BGN06
S
31
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BE - Benefit Enrollment and Maintenance (834)
CCYYMMDD
Use this date for the functional group creation date.
HHMM
Use this time for the creation time.
Must be identical to GE02.
B.9
X - Accredited Standards Committee X12
004010X095A1 - Draft Standards Approved for
Publication by ASC X12 Procedures Review
Board through October 1997, as published in
the Combined Implementation Guide.
834 Benefit Enrollment and Maintenance
Assigned by requester. Must be identical to SE02.
00 - Original
15 - Re-Submission
22 - Information Copy
If the original transaction has already been processed, an
incoming transaction using this code may be rejected by the
receiver. The rejection will be identified to the sender by
telephone or direct contact.
Transaction Set Identifier Code.
Use the transaction set reference number assigned by the
sender's application to uniquely identify this occurrence of the
transaction for future reference.
Transaction Set Creation Date.
Use this date to identify the date that the submitter created
the file.
Transaction Set Creation Time.
Use this time to identify the time of day that the submitter
created the file. This element is used as a time stamp to
uniquely identify the transmission.
Time Zone Code.
Use this time code if the sender and receiver are not in the
same time zone.
Transaction Set Identifier Code.
If BGN01 equals 15 or 22, then BGN06 should be used to
cross reference to the previously sent transaction.
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Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Action Code
Element
Use
Page
BGN07
BGN08
Not Used
R
31
31
BGN09
Not Used
S
31
32
REF01
REF02
REF03 thru
REF04
R
R
Not Used
32
33
33
S
R
34
34
34
34
35
35
35
36
REF - Transaction Set Policy Number
Reference Identification Qualifier
Reference Identification
DTP - File Effective Date
Date/Time Qualifier
DTP01
Date Time Period Format Qualifier
Date Time Period
Loop 1000A - Sponsor Name
N1 - Name
Entity Identifier Code
Name
DTP02
DTP03
N101
N102
R
R
R
R
R
S
Identification Code Qualifier
N103
R
36
Identification Code
N104
N105 thru
N106
R
Not Used
36
36
37
37
37
38
38
Loop 1000B - Payer
N1 - Name
Entity Identifier Code
Name
N101
N102
R
R
R
S
Identification Code Qualifier
N103
R
//HIPAA/DSR/Comp Guides/834
Possible Values
Description/Preferred Usage
Not Used
2 - Change (Update)
4 - Verify
Not Used
Required when the contract or trading partner agreement
identifies a Master Policy Number for use with electronic
enrollment.
38 - Master Policy Number
Master Policy Number
Not Used
007 - Effective
303 - Maintenance Effective
382 - Enrollment
388 - Payment Commencement
D8 - CCYYMMDD
To be sent when required by contract terms.
Date Time Qualifier
P5 - Plan Sponsor
Plan Sponsor Name.
This element may be used at the sender's discretion.
FI - Federal Taxpayer's Identification Number
ZZ - Mutually Defined
Sponsor Identifier
Not Used
IN - Insurer
Insurer Name.
This element may be used at the sender's discretion.
FI - Federal Taxpayer's Identification Number
XV - Health Care Financing Administration
National PlanID
17
Preferred Value:
FI
10/08/03
PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Identification Code
Element
N104
N105 thru
N106
Loop 1000C - TPA/Broker Name
Loop 1100C - TPA/Broker Account Information
Loop 2000 - Member Level Detail
INS - Insured Benefit
Use
Page
Possible Values
Description/Preferred Usage
R
38
Insurer Identification Code.
Preferred Value:
952931460
Not Used
38
Not Used
S
S
R
S
39
41
43
43
Not Used by PacifiCare
Not Used by PacifiCare
Subscriber information must precede dependent
information in a transmission, or the subscriber
information must have been submitted to the receiver in
a previous transmission.
Yes/No Condition or Response Code
INS01
R
44
N - No
Y - Yes
Insured Indicator
Individual Relationship Code
INS02
R
44
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Preferred Values:
01 - Spouse
18 - Self
19 - Child
53 - Life Partner/DP
Maintenance Type Code
INS03
R
45
001- Change
021 - Addition
024 - Cancellation or Termination
025 - Reinstatement
030 - Audit or Compare
Maintenance Reason Code
INS04
S
46
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Benefit Status Code
INS05
R
47
A - Active
C - Consolidated Omnibus Budget
Reconciliation Act (COBRA)
S - Surviving Insured
T - Tax Equity and Fiscal Responsibility Act
(TEFRA)
Medicare Plan Code
INS06
S
48
A - Medicare Part A
B - Medicare Part B
C - Medicare Part A and B
D - Medicare
E - No Medicare
//HIPAA/DSR/Comp Guides/834
18
Recommended: To be sent unless the trading partner
agreement between the sponsor and payer allow this data
element to not be sent.
This element is required if a member is being enrolled or
disenrolled in Medicare, is currently enrolled in Medicare or
has terminated or changed their Medicare enrollment.
10/08/03
PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Description/Preferred Usage
Consolidated Omnibus Budget Reconciliation Act
(COBRA) Qualifying
INS07
S
48
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
Qualifying Event Code.
This element is required if a member is being enrolled in or is
enrolled for a benefit covered by COBRA.
Employment Status Code
INS08
S
49
Required for subscriber.
Student Status Code
INS09
S
49
AO - Active Military - Overseas
AU - Active Military - USA
FT - Full-time
L1 - Leave of Absence
PT - Part-time
RT - Retired
TE - Terminated
F - Full-time
N - Not a Student
P - Part-time
Yes/No Condition or Response Code
INS10
S
49
N - No
Y - Yes
Handicap Indicator.
Required if the member is handicapped or to correct previous
report of handicapped status.
Date Time Period Format Qualifier
Date Time Period
INS11
INS12
S
S
50
50
D8 - CCYYMMDD
Send when required by X12 syntax.
Insured Individual Death Date.
Use this date for the date of death of the
subscriber/dependent.
Not Used
50
Not Used
Birth Sequence Number.
Required if reporting family members with the same birth
date, when needed for proper reporting, tracking or response
to benefits.
INS13 thru
INS16
Only use the Student Status Code when describing a nonspouse dependent whose age requires a qualifying condition
for enrollment.
Number
INS17
S
50
REF - Subscriber Number
Reference Identification Qualifier
Reference Identification
REF01
REF02
R
R
R
51
52
52
Not Used
52
Not Used
S
53
Should be used if the policy or group number applies to
all coverage data (all 2300 loops) that apply for this
member.
R
53
REF03 thru
REF04
REF - Member Policy Number
Reference Identification Qualifier
//HIPAA/DSR/Comp Guides/834
REF01
0F - Subscriber Number
Subscriber Identifier
Preferred Value:
SSN
1L - Group or Policy Number
19
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Reference Identification
Element
REF02
REF03 thru
REF04
REF - Member Identification Number
Use
Page
R
53
Insured Group or Policy Number.
Group Number Provided by PacifiCare.
Not Used
54
Not Used
S
55
Used to pass further identifying information on the
member. It should be used if the data is available.
Reference Identification Qualifier
REF01
R
55
Reference Identification
REF02
R
56
Not Used
56
S
57
R
R
Not Used
57
58
58
S
59
REF03 thru
REF04
REF - Prior Coverage Months
Reference Identification Qualifier
Reference Identification
REF01
REF02
REF03 thru
REF04
DTP - Member Level Dates
Possible Values
17 - Client Reporting Category
23 - Client Number
3H - Case Number
6O - Cross Reference Number
DX - Department/Agency Number
F6 - Health Insurance Claim (HIC) Number
Q4 - Prior Identifier Number
ZZ - Mutually Defined
Subscriber Supplemental Identifier.
DX 2 Digits State Codes supplied by PacifiCare:
25 - Arizona, 26 - Nevada, 28 - Medicare Supplement, 29 PPO, 33 - California, 36 - Washington, 43 - Oregon, 44 Oklahoma, 45 - Texas, 22 - Colorado
ZZ PLSN Codes supplied by PacifiCare.
Not Used
Required when the portability provisions of the Health
Insurance Portability and Accountability Act require
reporting of the number of months of prior health
coverage that meets the certification requirements of the
Act.
QQ - Unit Number
Prior Coverage Month Count
Not Used
Applicable dates, as listed in DTP01, are required when
enrolling a member or when the sponsor is informed of
any change to those dates. Only those dates that apply to
the particular insurance contract need to be sent.
Date/Time Qualifier
DTP01
R
59
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Date Time Period Format Qualifier
DTP02
R
60
D8 - CCYYMMDD
//HIPAA/DSR/Comp Guides/834
Description/Preferred Usage
20
Date Time Qualifier.
Preferred Values:
356 - Eligibility Begin
357 - Eligibility End
10/08/03
PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
R
R
S
60
61
61
Possible Values
Description/Preferred Usage
Date Time Period
Loop 2100A - Member Name
NM1 - Individual or Organizational Name
DTP03
Entity Identifier Code
NM101
R
62
74 - Corrected Insured
1L - Insured or Subscriber
Entity Type Qualifier
Name Last or Organization Name
Name First
Name Middle
NM102
NM103
NM104
NM105
R
R
R
S
62
62
62
62
1 - Person
Name Prefix
NM106
S
62
Subscriber Name Prefix.
Send if supplied by subscriber.
Name Suffix
NM107
S
62
Subscriber Name Suffix.
Send if supplied by subscriber.
Identification Code Qualifier
NM108
S
63
Identification Code
NM109
S
63
Subscriber Identifier.
Until the HIPAA Individual Identifier is available the SSN is to
be sent when available and allowed under confidentiality
regulations.
Preferred Value:
SSN - Social Security Number
Not Used
63
Not Used
S
64
Used when contact information is provided to the
sponsor about the member.
Communication Number Qualifier
PER01
PER02
PER03
R
Not Used
R
65
65
65
Communication Number
PER04
R
65
NM110 thru
NM111
PER - Member Communications Numbers
Contact Function Code
//HIPAA/DSR/Comp Guides/834
Status Information Effective Date
Required when enrolling a new member, changing a
member's demographic information, or terminating a
member.
Preferred Value:
1L - Insured or Subscriber
Subscriber Last Name
Subscriber First Name
Subscriber Middle Name.
Send if supplied by subscriber.
34 - Social Security Number
ZZ - Mutually Defined
Send when required by X12 syntax.
Preferred Value:
34 - Social Security Number
IP - Insured Party
EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
Not Used
Preferred Value:
TE - Telephone
HP - Home Phone Number
Telephone Number
21
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Communication Number Qualifier
PER05
S
65
Communication Number
PER06
S
66
Communication Number Qualifier
PER07
S
66
Communication Number
PER08
S
66
This element should be sent if additional communication
numbers are available.
PER09
Not Used
S
66
67
Not Used
Required when enrolling subscriber, when enrolling a
dependent and the dependent's address is different from
the subscriber and when changing a member's address.
R
S
67
67
Subscriber Address Line
Subscriber Address Line.
Required if a second address line exists.
S
68
Required when enrolling subscriber, when enrolling a
dependent and the dependent's address is different from
the subscriber and when changing a member's address.
Subscriber City Name
Subscriber State Code
Subscriber Postal Zone or ZIP Code
Required only if country is not USA.
Send when required by X12 syntax.
N3 - Member Residence Street Address
Address Information
Address Information
N301
N302
N4 - Member Residence City, State, Zip Code
City Name
State or Province Code
Postal Code
Country Code
Location Qualifier
N401
N402
N403
N404
N405
R
R
R
S
S
68
68
69
69
69
Location Identifier
N406
S
69
S
70
DMG - Member Demographics
//HIPAA/DSR/Comp Guides/834
EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
Description/Preferred Usage
Send when required by X12 syntax.
This element should be sent if additional communication
numbers are available.
EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
60 - Area
CY - Country/Parish
Send when required by X12 syntax.
Location Identification Code.
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
Required when enrolling a new member, changing a
member's demographic information, or terminating a
member.
22
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Description/Preferred Usage
Date Time Period Format Qualifier
Date Time Period
Gender Code
DMG01
DMG02
DMG03
R
R
R
70
71
71
Marital Status Code
DMG04
S
71
Race or Ethnicity Code
DMG05
S
72
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
Citizenship Status Code
DMG06
S
72
1 - U.S. Citizen
2 - Non-Resident Alien
3 - Resident Alien
4 - Illegal Alien
5 - Alien
6 - U.S. Citizen - Non-Resident
7 - U.S. Citizen - Resident
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
DMG07 thru Not Used
DMG09
D8 - CCYYMMDD
Member Birth Date
F - Female
M - Male
U - Unknown
Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
73
Not Used
ICM - Member Income
S
74
Not Used by PacifiCare
AMT - Member Policy Amounts
HLH - Member Health Information
LUI - Member Language
Loop 2100B - Incorrect Member Name
Loop 2100C - Member Mailing Address
S
S
S
S
S
76
77
79
81
86
Not Used by PacifiCare
Not Used by PacifiCare
Not Used by PacifiCare
Not Used by PacifiCare
Send this loop if the member has a mailing address
different from the residence address sent in loop 2100A.
S
R
R
Not Used
86
87
87
87
NM1 - Individual or Organizational Name
Entity Identifier Code
Entity Type Qualifier
NM101
NM102
NM103 thru
NM111
31 - Postal Mailing Address
1 - Person
Not Used
N3 - Member Mail Street Address
Address Information
Address Information
N301
N302
S
R
S
88
88
88
Send when needed for address in loop 2100C.
Subscriber Address Line
Subscriber Address Line.
Required if a second address line exists.
N4 - Member Mail City, State, Zip
City Name
N401
S
R
89
89
Send when needed for address in loop 2100C.
Subscriber City Name
//HIPAA/DSR/Comp Guides/834
23
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
State or Province Code
Postal Code
Country Code
Element
N402
N403
N404
N405 thru
N406
Loop 2100D - Member Employer
Loop 2100E - Member School
Loop 2100F - Custodial Parent
Loop 2100G - Responsible Person
Loop 2200 - Disability Information
DSB - Disability Information
Disability Type Code
DSB01
DSB02 thru
DSB06
Use
Page
R
R
S
Not Used
89
89
90
90
Subscriber State Code
Subscriber Postal Zone or ZIP Code
Required only if country is not USA.
Not Used
S
S
S
S
S
91
99
107
116
125
Not Used by PacifiCare
Not Used by PacifiCare
Not Used by PacifiCare
Not Used by PacifiCare
Use to report a disability of either a subscriber or a
dependent within the appropriate 2000 loop.
S
R
125
125 1 - Short Term Disability
2 - Long Term Disability
3 - Permanent or Total Disability
4 - No Disability
Not Used
Possible Values
Description/Preferred Usage
126
Not Used
Product/Service ID Qualifier
DSB07
S
126 DX - International Classification of Diseases
Clinical Modification (ICD-9-CM) - Diagnosis
Product or Service ID Qualifier.
Send when required by X12 syntax.
Medical Code Value
DSB08
S
126
Diagnosis Code.
Use DSB08 to indicate if the reason for disability is ESRD.
The only allowed value is 585 - End Stage Renal Disease.
S
127
Used to send the first and last date of disability.
Date Time Qualifier
DTP - Disability Eligibility Dates
Date/Time Qualifier
DTP01
R
127 360 - Disability Begin
361 - Disability End
Date Time Period Format Qualifier
DTP02
R
127 D8 - CCYYMMDD
Date Time Period
DTP03
R
128
Disability Eligibility Date
S
129
Required when enrolling a new member or when adding,
updating or removing coverage from an existing member.
HD01
S
R
129
129 Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
HD02
Not Used
Loop 2300 - Health Coverage
HD - Health Coverage
Maintenance Type Code
//HIPAA/DSR/Comp Guides/834
130
Not Used
24
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Description/Preferred Usage
Insurance Line Code
HD03
R
130 Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
Plan Coverage Description
HD04
S
131
Use this element when additional information is needed by
the insurer to describe the exact type of coverage being
provided.
Coverage Level Code
HD05
S
131 Refer to the Combined 834 Transaction Set
Implementation Guide for a list of values.
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
132
Not Used
HD06 thru
HD11
DTP - Health Coverage Dates
Date/Time Qualifier
DTP01
Not Used
R
R
133
133 303 - Maintenance Effective
348 - Benefit Begin
349 - Benefit End
543 - Last Premium Paid Date
Date Time Qualifier
Date Time Period Format Qualifier
Date Time Period
AMT - Health Coverage Policy
REF - Health Coverage Policy Number
DTP02
DTP03
R
R
S
S
134 D8 - CCYYMMDD
134
135
136
Reference Identification Qualifier
REF01
R
136 17 - Client Reporting Category
1L - Group or Policy Number
ZZ - Mutually Defined
Preferred Value:
1L - Insured or Subscriber
Reference Identification
REF02
R
137
Insured Group or Policy Number.
Group Number Provided by PacifiCare.
Not Used
137
Not Used
S
S
138
140
Not Used by PacifiCare
Use to provide information about primary care or
capitated physicians and pharmacies chosen by the
enrollee in a managed care plan when that selection is
made through the sponsor.
S
140
R
140
REF03 thru
REF04
IDC - Identification Card
Loop 2310 - Provider Information
LX - Assigned Number
Assigned Number
//HIPAA/DSR/Comp Guides/834
LX01
Coverage Period
Not Used by PacifiCare
Used to identify a policy or group number for a particular
insurance product if it has not already been identified in
either REF02, position 1-030 or REF02, position 2-020.
Use this sequential number for LX loops for this insured
person.
25
10/08/03
PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
Page
Possible Values
Description/Preferred Usage
NM1 - Provider Name
Entity Identifier Code
NM101
R
R
141
142 3D - Obstetrics and Gynecology Facility
OD - Doctor of Optometry
P3 - Primary Care Provider
QA - Pharmacy
QN - Dentist
Y2 - Managed Care Organization
Entity Type Qualifier
NM102
R
142 1 - Person
2 - Non-Person Entity
Name Last or Organization Name
NM103
S
142
Name First
NM104
S
142
Name Middle
NM105
S
142
Provider Middle Name.
The name should only be used when the sponsor is not able
to provide the standard ID number.
Name Prefix
NM106
S
142
Provider Name Prefix.
The name should only be used when the sponsor is not able
to provide the standard ID number.
Name Suffix
NM107
S
143
Provider Name Suffix.
The name should only be used when the sponsor is not able
to provide the standard ID number.
Identification Code Qualifier
NM108
S
143 34 - Social Security Number
FI - Federal Taxpayer's Identification Number
SV - Service Provider Number
XX - Health Care Financing Administration
National Provider Identifier
Identification Code
NM109
S
143
Provider Identifier.
Required when available to the sponsor and transmission is
not prohibited by local, state, or Federal law.
Entity Relationship Code
NM110
R
143 25 - Established Patient
26 - Not Established Patient
72 - Unknown
This element indicates whether or not the member is an
existing patient of the provider.
NM111
Not Used
S
143
144
Not Used
To be sent when required in the insurance contract
between the sponsor and the payer.
R
144
Member City Name
N4 - Provider City, State, ZIP Code
City Name
//HIPAA/DSR/Comp Guides/834
N401
Preferred Value:
P3 - Primary Care Provider
Provider Last or Organization Name.
The name should only be used when the sponsor is not able
to provide the standard ID number.
Provider First Name.
The name should only be used when the sponsor is not able
to provide the standard ID number.
26
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PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
Element
Use
State or Province Code
Postal Code
Country Code
Location Qualifier
N402
N403
N404
N405
R
R
S
S
Location Identifier
N406
S
PER - Provider Communications Numbers
Contact Function Code
Page
Possible Values
Description/Preferred Usage
144
145
145
145 60 - Area
CY - Country/Parish
RJ - Region
145
Member State Name
Member Postal Zone of Zip Code
Required only if country is not USA.
Send when required by X12 syntax.
146
147 IC - Information Contact
147
147 EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
147
147 EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
To be sent when available.
Location Identification Code.
This data should only be transmitted when such transmission
is required under the insurance contract between the sponsor
and payer and allowed by federal and state regulations.
Communication Number Qualifier
PER01
PER02
PER03
S
R
Not Used
R
Communication Number
Communication Number Qualifier
PER04
PER05
R
S
Communication Number
PER06
S
147
This element should be sent if additional communication
numbers are available.
Communication Number Qualifier
PER07
S
Send when required by X12 syntax.
Communication Number
PER08
S
148 EM - Electronic Mail
EX - Telephone Extension
FX - Facsimile
HP - Home Phone Number
TE - Telephone
WP - Work Phone Number
148
PER09
Not Used
S
S
148
149
151
Not Used
Not Used by PacifiCare
Not Used by PacifiCare
PLA - PCP Change Reason
Loop 2320 - Coordination of Benefits
//HIPAA/DSR/Comp Guides/834
27
Not Used
Send when required by X12 syntax.
This element should be sent if additional communication
numbers are available.
10/08/03
PacifiCare Health Systems – 834 Transaction Companion Guide
Combined 834 Transaction Set – 004010X095 & 004010X095A1
Segment
SE - Transaction Set Header
Number of Included Segments
Transaction Set Control Number
IEA - Interchange Control Trailer
Number of Included Functional Groups
Interchange Control Number
GE - Functional Group Trailer
Number of Transaction Sets Included
Group Control Number
//HIPAA/DSR/Comp Guides/834
Element
SE01
SE02
IEA01
IEA02
GE01
GE02
Use
Page
R
R
159
159
R
R
R
R
R
R
R
159
B.7
Possible Values
Description/Preferred Usage
Transaction Segment Count.
Assigned by requester. Must be identical to ST02.
A control number assigned by the interchange sender.
B.10
Assigned number originated and maintained by the
sender. Must be identical to GS06.
28
10/08/03