834 (Benefits and Enrollment) Schema

Resources:

Member Coverage

Main object for 834, contains the member and their health coverage information.

Loop: 2000, Segment: INS JSON Example CSV Example Interactive Example Open API Schema

Name	Description	Type	EDI Element
transactionControlNumber	Transaction control number	String	ST02
transactionSetPurposeCode	Transaction set purpose code	String	BGN01
originatorApplicationTransactionId	Originator application transaction id	String	BGN02
transactionCreationDateTime	Transaction creation date time	Date and Time	BGN03,BGN04
transactionActionCode	Transaction action code	String	BGN08
fileEffectiveDates	File effective dates	List of Date	DTP
masterPolicyNumber	Master policy number	String	REF02 *34
sponsor	Sponsor	PartyIdName	Loop: 1000A
insurer	Insurer	PartyIdName	Loop: 1000B
tpas	Tpas	List of Tpa	Loop: 1000C
memberIndicator	Member indicator	String	INS01
relationshipCode	Relationship code	String	INS02
maintenanceTypeCode	Maintenance type code	String	INS03
maintenanceReasonCode	Maintenance reason code	String	INS04
benefitStatusCode	Benefit status code	String	INS05
cobraEventCode	Cobra event code	String	INS07
employmentStatusCode	Employment status code	String	INS08
studentStatusCode	Student status code	String	INS09
handicapIndicator	Handicap indicator	String	INS10
confidentialityCode	Confidentiality code	String	INS13
birthSequenceNumber	Birth sequence number	Integer	INS17
identifier	Member identifier	String	REF02 *0F
groupOrPolicyNumber	Group or policy number	String	REF02 *1L
supplementalIdentifiers	Supplemental identifiers	List of Reference	REF
statusInfoEffectiveDates	Status info effective dates	List of Date	DTP
member	Member	Member	NM1 *IL Loop: 2100A
contractAmounts	Member policy amounts from the member loop 2100A	List of Amount	AMT
mailingAddress	Member mailing address	Address
employers	Employers	List of Party	Loop: 2100D
schools	Schools	List of Party	Loop: 2100E
custodialParent	Custodial parent	Party	Loop: 2100F
responsiblePersons	Responsible persons	List of Party	Loop: 2100G
reportingCategories	Reporting categories	List of ReportingCategory	Loop: 2750
healthCoverages	Health coverages	List of HealthCoverage	Loop: 2300
transaction	Parent EDI transaction for this object	Transaction834

Member

Loop: 2100A, Segment: NM1 Open API Schema

Extends: PersonWithDemographic

Name	Description	Type	EDI Element
maritalStatusCode	Marital status code	String	DMG04
ethnicityCode	Ethnicity code	String	DMG05
citizenshipCode	Citizenship code	String	DMG06
employmentClassCodes	Employment class codes	List of String	EC01,EC02,EC03
wageFrequencyCode	Wage frequency code	String	ICM01
wageAmount	Wage amount	Number	ICM02
workHoursCount	Work hours count	Number	ICM03
employerLocationIdentificationCode	Employer location identification code	String	ICM04
salaryGradeCode	Salary grade code	String	ICM05
healthRelatedCode	Health related code	String	HLH01
height	Height	Number	HLH02
weight	Weight	Number	HLH03

Health Coverage

Loop: 2300, Segment: HD Open API Schema

Name	Description	Type	EDI Element
maintenanceTypeCode	Maintenance type code	String	HD01
insuranceLineCode	Insurance line code	String	HD03
planDescription	Plan description	String	HD04
coverageLevelCode	Coverage level code	String	HD05
lateEnrollmentIndicator	Late enrollment indicator	String	HD09
coverageDates	Coverage dates	List of Date	DTP
contractAmounts	Contract amounts	List of Amount	AMT
groupOrPolicyNumbers	Group or policy numbers	List of Reference	REF
priorCoverageMonthCount	Prior coverage month count	String	REF02 *QQ
providers	Providers	List of Party
cobs	Coordination of Benefits	List of CoordinationOfBenefits

Organization ID and Name

Open API Schema

Name	Description	Type	EDI Element
entityRole	Entity role View codes and descriptions	String Required	NM101, N101
entityType	Type of this entity: 'BUSINESS' for organization, 'INDIVIDUAL' for person	String Required	NM102
identificationType	Identification type, e.g., NPI or EIN. This is a qualifier code translated to a string constant (enum)	String	NM108, N103
identifier	Identifier	String	NM109, N104
taxId	Tax id	String	REF02 TJ, REF02 SY, REF02 *EI
lastNameOrOrgName	Organization name or person last name	String	NM103, N102
firstName	First name	String	NM104
middleName	Middle name	String	NM105

Organization or Person (Party)

Open API Schema

Extends: PartyIdName

Name	Description	Type	EDI Element
address	Address	Address
contacts	Contacts	List of ContactInfo
additionalIds	Other identifications	List of Reference	REF

TPA

Loop: 1000C, 1100C Open API Schema

Extends: Party

Name	Description	Type	EDI Element
accountNumber	Account number	String	ACT01
accountNumber2	Account number2	String	ACT06

Coordination of Benefits

Loop: 2320, Segment: COB Open API Schema

Name	Description	Type	EDI Element
payerResponsibilitySequenceCode	Payer responsibility sequence code	String	COB01
groupOrPolicyNumber	Group or policy number	String	COB02
coordinationOfBenefitsCode	Coordination of benefits code	String	COB03
additionalIdentifiers	Additional identifiers	List of Reference	REF
dateFrom	Date from	Date	DTP03 *344
dateTo	Date to	Date	DTP03 *345
insurers	Insurers	List of Party

Address

Open API Schema

Name	Description	Type	EDI Element
line	Line	String	N301
line2	Line2	String	N302
city	City	String	N401
stateCode	State code	String	N402
zipCode	Zip code	String	N403
countryCode	Country code	String	N404

Contact Info

Segment: PER Open API Schema

Name	Description	Type	EDI Element
functionCode	Function code	String Required	PER01
name	Name	String	PER02
contactNumbers	Contact numbers	List of ContactNumber

Contact Number

Segment: PER Open API Schema

Name	Description	Type	EDI Element
type	Type of contact number, such as PHONE, EMAIL, URL	String Required	PER03,PER05,PER07
number	Number	String Required	PER04,PER06,PER08

Reporting Category

Open API Schema

Name	Description	Type	EDI Element
name	Name	String	N102
identifierQualifierCode	Identifier qualifier code	String	REF01
identifierType	Identifier type	String	REF01
identifier	Identifier	String	REF02
date	Effective date	Date	DTP03 *007
dateTo	End date	Date	DTP03

Date

Segment: DTP Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code specifying type of date or time	String	DTP01
type	Type of date; qualifier code translated to a mnemonic string constant (enum) View codes and descriptions	String	DTP01
date	The date value or the first date of the date range ('RD8' qualifier)	Date	DTP03
dateTo	The second date if the value is the date range ('RD8' qualifier), otherwise null	Date	DTP03

Reference Identifications

Segment: REF Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code qualifying the reference identification	String Required	REF01
type	Type of reference; qualifier code as a string constant (enum) View codes and descriptions	String	REF01
identification	Reference identification	String Required	REF02

Amount

Segment: AMT Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code specifying the type of amount (amount qualifier code)	String Required	AMT01
type	Type of amount; qualifier code translated to a mnemonic string constant (enum) View codes and descriptions	String	AMT01
amount	Amount	Number Required	AMT02

Quantity

Segment: QTY Open API Schema

Name	Description	Type	EDI Element
qualifierCode	Code specifying the type of quantity (quantity qualifier code)	String Required	QTY01
type	Type of quantity; qualifier code translated to a mnemonic string constant (enum) View codes and descriptions	String	QTY01
quantity	Quantity	Number Required	QTY02

EDI Transaction Info

Open API Schema

Name	Description	Type	EDI Element
controlNumber	Control number	String	ST02
transactionType	Transaction type translated to string constant, PROF for 837P, INST for 837I, etc.	String	ST01, ST03
purposeCode	Purpose code	String	BGN01
originatorApplicationTransactionId	Originator application transaction id	String	BGN02
creationDate	Creation date	Date	BGN03
creationTime	Creation time	Time	BGN04
originalTransactionSetReferenceNumber	Original transaction set reference number	String	BGN06
actionCode	Action code	String	BGN08
transactionSetIdentifierCode	Transaction set identifier code	String	ST01
implementationConventionReference	Implementation convention reference	String	ST03
fileEffectiveDates	File effective dates	List of Date	DTP
controlTotals	Control totals	List of Quantity	QTY
fileInfo	File info	FileInfo

File Info

Open API Schema

Name	Description	Type
name	File name	String
url	URL of the file, including the full path	String
lastModifiedDateTime	Last modified date and time of the file	Date and Time