ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

X095A1

ICRs Contained in 45 CFR Part 162; HIPAA Standards for Electronic Transactions

OMB: 0938-0866

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2013-03-29 - Reinstatement without change of a previously approved collection

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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

National Electronic Data Interchange
Transaction Set Implementation Guide

A
D
D
E
N
D
A

Benefit Enrollment
and Maintenance
834
ASC X12N 834 (004010X095A1)

October 2002
OCTOBER 2002

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

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© 2002 WPC
Copyright for the members of ASC X12N by Washington Publishing Company.
Permission is hereby granted to any organization to copy and distribute this material internally as long as this copyright statement is
included, the contents are not changed, and the copies are not sold.

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7

OCTOBER 2002

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X95A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

1 Introduction to Modified Pages
This document is addenda to the X12N Benefit Enrollment and Maintenance Implementation Guide, originally published May 2000 as 004010X095. As a result
of the post publication review process, items were identified that could be considered impediments to implementation. These items were passed to the X12N
Health Care Work Group that created the original Implementation Guide for their
review.
Modifications based on those comments were reflected in a draft version of the
Addenda to the X12N 004010X095 Implementation Guide. Since the X12N
004010X095 Implementation Guide is named for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), an NPRM Draft Addenda went
through a Notice of Proposed Rule Making (NPRM) comment process that began
on May 31, 2002. Only the modifications noted in the NPRM Draft Addenda were
considered in the NPRM and X12N review processes. No changes to the Addenda were necessary based on comments received during the NPRM process
and X12N’s own review processes. The Addenda was approved for publication
by X12N on October 10, 2002. When using the X12N Benefit Enrollment and
Maintenance Implementation Guide, originally published May 2000 as
004010X095 and incorporating the changes identified in the Addenda, the value
used in GS08 must be “004010X095A1".
Each of the changes made to the 004010X095 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. For
convenience, the affected 004010X095 Implementation Guide page number is
noted at the bottom of the page. Please note that as a result of insertion or deletion of material Addenda pages may not begin or end at the same place as the
original referenced page. Because of this, Addenda pages are not page for page
replacements and the original pages should be retained.
Changes in the Addenda may have caused changes to the Data Element Dictionary and the Data Element Name Index (Appendix E in the original Implementation Guide), but these changes are not identified in the Addenda. Changes in the
Addenda may also have caused changes to the Examples and the EDI Transmission Examples (Section 4 in the original Implementation Guide), again these are
not identified in the Addenda.

OCTOBER 2002

004010X95A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X95A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

If the termination date is passed at the HD level for any member; the DTP segment in position 270, loop 2300; then coverage for that specific insurance product for that member will be terminated, effective on that date. Coverage for other
insurance products for that member will not be affected nor will coverage for
other members linked to the same subscriber.
Termination dates are not to be sent at both the HD and the INS levels for a particular occurrence of loop 2000.
Terminating all covered insurance products for a dependent at the HD level is the
equivalent of terminating that dependent at the INS level. Terminating all insurance products for a subscriber at the HD level is different, in that there may be
dependents that continue to be covered, i.e. - dependent only plans. A subscriber
with all insurance product coverages terminated will be terminated as a member
only if there are no dependents linked to that subscriber.
In the case of a transfer from one coverage to another, it is necessary to terminate the old coverage and then add the new coverage. An add to a new coverage must never be assumed to result in the automatic termination of the prior coverage.

2.6

Updates Versus Full File Audits
The 834 transaction can be used to provide either updates to the enrollment database or full file audits.
An update is either an “add”, “terminate” or “change” request. The transaction
only contains information about the changed members. This is identified in
BGN08 by a code value of ’2’, Change (Update).

Paragraph
revised

A full file audit lists all current members, whether involved in a change or not.
This facilitates keeping the sponsor’s and payer’s systems in sync. This is not intended to contain a history of all previous enrollments. The full file audit is intended to identify all active members, at a given point in time and may or may not
include terminated members based on your Trading Partner Agreement. This
type of transaction is identified by a BGN08 code value of ’4’, Verify. Any response back to the sponsor from the received transactions are outside the scope
of the 834 and are the responsibility of the sponsor and payer.
The most efficient and preferred method for regular maintenance of enrollment
files is to use ’Change (Update)’ transactions. Periodic audit files can be used to
verify synchronization.
When required by sponsor’s system limitations, full replacement files can be
used to report all enrollees. Because this model is more costly and requires
more resources to process, it is not recommended. ’Verify’ should not be used
for regular, daily, processing. It is recommended that this be used no more frequently than monthly.

2.7

Coverage Levels and Dependents
Differences exist in how Payers handle dependents. Some Payers identify a
coverage level (HD05) for the subscriber which defines the coverage for eligible
dependents as well. Other Payers need detailed information on each dependent
in order to maintain their databases. Still other Payers require both types of
information.

OCTOBER 2002

Original Page Number 14 dated May 2000

004010X095A1 • 834 • 2000 • REF
SUBSCRIBER NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

SUBSCRIBER
004010X095A1NUMBER
• 834 • 2000 • REF

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

Subscriber Number
The assignment of the Subscriber Number is
designated within the Insurance Contract.

New note added to code
1000091
REQUIRED

REF02

DEFINITION

127

Reference Identification

1/30

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Subscriber
SYNTAX:

Identifier

R0203

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

Original Page Number 52 dated May 2000

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REFERENCE IDENTIFICATION
REF

004010X095A1 • 834 • 2000 • REF
MEMBER POLICY NUMBER

MEMBER
004010X095A1
POLICY
NUMBER
• 834
• 2000 • REF

IMPLEMENTATION

MEMBER POLICY NUMBER
Loop: 2000 — MEMBER LEVEL DETAIL
Usage: SITUATIONAL
Repeat: 1
Notes:

1
111

1. This segment should be used if the policy or group number applies to
all coverage data (all 2300 loops) that apply for this member.
2. This segment is required unless the policy number is sent in the REF
segment, loop 2300 position 290.

2
126

Example: REF✽1L✽9CC4123~

0
111
STANDARD

REF Reference Identification
Level: Detail
Position: 020
Loop: 2000
Requirement: Mandatory
Max Use: >1
Purpose: To specify identifying information
Set Notes:

1. The REF segment is required to link the dependent(s) to the subscriber.

Syntax:

1. R0203
At least one of REF02 or REF03 is required.

DIAGRAM

REF01

REF

✽

128

Reference
Ident Qual
M

2/3

REF02

127

Reference
Ident

✽
X

REF03

352

REF04

✽ Description ✽

AN 1/30

AN 1/80

C040

Reference
Identifier

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

REF01

DATA
ELEMENT

128

NAME

ATTRIBUTES

Reference Identification Qualifier

2/3

Code qualifying the Reference Identification
CODE

New note added to code
1000092

OCTOBER 2002

DEFINITION

Group or Policy Number
The payer is responsible for making the assignment
of the Group or Policy Number.

Original Page Number 53 dated May 2000

004010X095A1 • 834 • 2000 • REF
MEMBER IDENTIFICATION NUMBER

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

MEMBER
004010X095A1
IDENTIFICATION
• 834 • 2000NUMBER
• REF

Client Number
To be used to pass a payer specific identifier for a
member. Not to be used after the HIPAA standard
National Identifier for Individuals is implemented.

1263

New code value

Case Number

Cross Reference Number
This number is used to tie the Surviving Insured
back to the original Subscriber ID.

1000093
DX

Department/Agency Number
Use when members in a coverage group are set up
as different departments or divisions under the
terms of the insurance policy.

1155

Health Insurance Claim (HIC) Number
Use when reporting Medicare eligibility for a
member until the National Identifier is mandated for
use.

1156

Prior Identifier Number
Use to pass the Identifier Number under which the
member had previous coverage with the payer. This
could be the result of a change in employment or
coverage that resulted in a new ID number being
assigned but left the member covered by the same
payer.

1157

Mutually Defined
Use this code to transmit the title of the members
employment position.

1264
REQUIRED

REF02

127

Reference Identification

1/30

Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Subscriber
SYNTAX:

Supplemental Identifier

R0203

NOT USED

REF03

352

Description

NOT USED

REF04

C040

REFERENCE IDENTIFIER

Original Page Number 56 dated May 2000

1/80

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X095A1 • 834 • 2100A • NM1
MEMBER NAME

MEMBER
004010X095A1
NAME• 834 • 2100A • NM1

IMPLEMENTATION

MEMBER NAME
Loop: 2100A — MEMBER NAME Repeat: 1
Note changed

Usage: REQUIRED
Repeat: 1
Notes:

009
100
4

1. REQUIRED when enrolling a new member, changing a member’s
demographic information, or terminating a member.

Example: NM1✽IL✽1✽SMITH✽JOHN✽M✽✽SR~

1
101
STANDARD

NM1 Individual or Organizational Name
Level: Detail
Position: 030
Loop: 2100 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
Syntax:

1. P0809
If either NM108 or NM109 is present, then the other is required.
2. C1110
If NM111 is present, then NM110 is required.

DIAGRAM

NM101

NM1 ✽
M

NM107

NM102

✽

2/3

AN 1/10

1065

Entity Type
Qualifier
M

1039

Name
Suffix

✽

OCTOBER 2002

Entity ID
Code

NM109

ID Code
Qualifier
X

✽

1/2

1035

Name Last/
Org Name

1/1

NM108

✽

NM103

AN 2/80

706

2/2

1037

Name
Middle

✽

Entity
Relat Code
X

NM105

AN 1/25

NM110

✽

1036

Name
First

✽

AN 1/35

ID
Code

✽

NM104

AN 1/10

Entity ID
Code
O

1038

Name
Prefix

✽

AN 1/25

NM111

✽

NM106

2/3

Original Page Number 61 dated May 2000

004010X095A1 • 834 • 2100A • DMG
MEMBER DEMOGRAPHICS

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

MEMBER
004010X095A1
DEMOGRAPHICS
• 834 • 2100A • DMG

IMPLEMENTATION

MEMBER DEMOGRAPHICS
Loop: 2100A — MEMBER NAME
Note changed

Usage: SITUATIONAL
Repeat: 1
Notes:

009
100
4

1. REQUIRED when enrolling a new member, changing a member’s
demographic information, or terminating a member.
2. This segment is REQUIRED for dependent changes records until the
National Individual Identifier is mandated.

6
119

Example: DMG✽D8✽19450915✽F✽M~

4
101
STANDARD

DMG Demographic Information
Level: Detail
Position: 080
Loop: 2100
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
Syntax:

1. P0102
If either DMG01 or DMG02 is present, then the other is required.

DIAGRAM

DMG01

DMG ✽

1250

Date Time
format Qual
X

✽
X

DMG08

Country
Code
2/3

✽

1251

Date Time
Period

2/3

DMG07

✽

DMG02

1068

Gender
Code

✽

AN 1/35

659

Basis of
Verif Code
O

DMG03

DMG09

1/2

1067

DMG05

1109

DMG06

1066

Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1

1/1

1/2

380

Quantity

✽

DMG04

1/15

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

DMG01

DATA
ELEMENT

1250

NAME

ATTRIBUTES

Date Time Period Format Qualifier

2/3

Code indicating the date format, time format, or date and time format
SYNTAX:

P0102

CODE

Original Page Number 70 dated May 2000

DEFINITION

Date Expressed in Format CCYYMMDD

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

REQUIRED

DMG02

1251

004010X095A1 • 834 • 2100A • DMG
MEMBER DEMOGRAPHICS

Date Time Period

1/35

Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Member
SYNTAX:

P0102

SEMANTIC:

REQUIRED

DMG03

1068

Birth Date

DMG02 is the date of birth.

Gender Code

1/1

Code indicating the sex of the individual
CODE

Female

Male

Unknown
This code is to be used when the gender is unknown
or when it can not be report for any other reason.
Unknown should only be used when there is no way
of obtaining the gender of the member. This may
cause problems in some systems and should be
avoided.

1274

SITUATIONAL

DEFINITION

DMG04

1067

Marital Status Code

1/1

Code defining the marital status of a person

1116

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. This element is
NOT USED when the member identified in the related INS segment
is not the subscriber. See section 2.7, “Coverage Levels and
Dependents”, for additional information.
CODE

Registered Domestic Partner

Divorced

Single

Married

Unreported

Separated

Unmarried (Single or Divorced or Widowed)
This code should be used if the previous status is
unknown.

1273

OCTOBER 2002

DEFINITION

Widowed

Legally Separated

Original Page Number 71 dated May 2000

004010X095A1 • 834 • 2100A • DMG
MEMBER DEMOGRAPHICS

SITUATIONAL

DMG05

1109

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Race or Ethnicity Code

1/1

Code indicating the racial or ethnic background of a person; it is normally selfreported; Under certain circumstances this information is collected for United
States Government statistical purposes

1116

CODE

New code values

SITUATIONAL

DMG06

1066

DEFINITION

Not Provided

Not Applicable

Asian or Pacific Islander

Black

Caucasian

Subcontinent Asian American

Other Race or Ethnicity

Asian Pacific American

Native American

Hispanic

American Indian or Alaskan Native

Native Hawaiian

Black (Non-Hispanic)

White (Non-Hispanic)

Pacific Islander

Mutually Defined

Citizenship Status Code

1/2

Code indicating citizenship status

1116

DEFINITION

U.S. Citizen

Non-Resident Alien

Resident Alien

Original Page Number 72 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

004010X095A1 • 834 • 2100G • NM1
RESPONSIBLE PERSON

004010X095A1 •PERSON
RESPONSIBLE
834 • 2100G • NM1

ELEMENT SUMMARY

USAGE

REF.
DES.

REQUIRED

NM101

DATA
ELEMENT

NAME

ATTRIBUTES

Entity Identifier Code

2/3

Code identifying an organizational entity, a physical location, property or an
individual
CODE

Person or Other Entity Legally Responsible for a
Child
Used to identify a legal indemnity situation.

1291

This code should be used when a Qualified Medical
Child Support Order (QMSCO) is present.

New text added to note
EI

Executor of Estate
This is used when the subscriber is deceased and
the executor/responsible party is other than a
surviving spouse.

1292

EXS

Ex-spouse
This is used to identify a separated spouse under a
separation agreement, or that the member is the
divorced spouse and self responsible. This is NOT
USED to identify the custodial parent for dependent
children after a divorce.

1293

REQUIRED

DEFINITION

NM102

1065

Guardian

Power of Attorney

Responsible Party

Entity Type Qualifier

1/1

1/35

1/25

Code qualifying the type of entity
SEMANTIC:

NM102 qualifies NM103.

CODE

1
REQUIRED

NM103

1035

DEFINITION

Person

Name Last or Organization Name
Individual last name or organizational name
INDUSTRY: Responsible

REQUIRED

NM104

1036

Party Last or Organization Name

Name First
Individual first name
INDUSTRY: Responsible

SITUATIONAL

NM105

1037

Party First Name

Name Middle
Individual middle name or initial
INDUSTRY: Responsible

1208

OCTOBER 2002

Party Middle Name

Send if supplied by the subscriber.

Original Page Number 115 dated May 2000

004010X095A1 • 834 • 2310 • NM1
PROVIDER NAME

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

PROVIDER
004010X095A1
NAME
• 834 • 2310 • NM1

SITUATIONAL

NM107

1039

Name Suffix

1/10

Suffix to individual name
INDUSTRY: Provider

Name Suffix

The name should only be used when the sponsor is not able to
provide the standard ID number.

1213
SITUATIONAL

NM108

Identification Code Qualifier

1/2

Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:

P0809

Send when required by X12 syntax.

1217

CODE

DEFINITION

Social Security Number
The social security number may not be used for any
Federally administered programs such as Medicare
or CHAMPUS.

1270

New code value

Federal Taxpayer’s Identification Number

Service Provider Number
This is a number assigned by the payer used to
identify a provider.

1000095
XX

SITUATIONAL

NM109

Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.

Identification Code

2/80

Code identifying a party or other code
INDUSTRY: Provider
SYNTAX:

Identifier

P0809

Required when available to the sponsor and transmission is not
prohibited by local, state, or Federal law.

1333
REQUIRED

NM110

706

Entity Relationship Code

2/2

Code describing entity relationship
SYNTAX:

C1110

COMMENT:

NM110 and NM111 further define the type of entity in NM101.

This element indicates whether or not the member is an existing
patient of the provider.

1214

CODE

NOT USED

NM111

DEFINITION

Established Patient

Not Established Patient

Unknown

Entity Identifier Code

Original Page Number 142 dated May 2000

2/3

OCTOBER 2002

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IMPLEMENTATION GUIDE

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

Data elements are assigned a unique reference number. Each data element has
a name, description, type, minimum length, and maximum length. For ID type
data elements, this guide provides the applicable ASC X12 code values and their
descriptions or references where the valid code list can be obtained.
Each data element is assigned a minimum and maximum length. The length of
the data element value is the number of character positions used except as
noted for numeric, decimal, and binary elements.
The data element types shown in matrix A4, Data Element Types, appear in this
implementation guide.
SYMBOL
TYPE
Nn
Numeric
R
Decimal
ID
Identifier
AN
String
DT
Date
TM
Time
B
Binary
Matrix A4. Data Element Types

A.1.3.1.1

Numeric
A numeric data element is represented by one or more digits with an optional
leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be
transmitted with the data.
This set of guides denotes the number of implied decimal positions. The representation for this data element type is “Nn” where N indicates that it is numeric
and n indicates the number of decimal positions to the right of the implied decimal point.
If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a
value of 12.34.
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. The length of a numeric type data element does not include
the optional sign.

A.1.3.1.2

Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element
type is represented as “R.”
The decimal point always appears in the character stream if the decimal point is
at any place other than the right end. If the value is an integer (decimal point at
the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) should not be transmitted.

OCTOBER 2002

Original Page Number A.5 dated May 2000

004010X095A1 • 834
BENEFIT ENROLLMENT AND MAINTENANCE

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for
example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point.
EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.
New note

For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in
Data Element 782 (Monetary Amount) will be limited to a maximum length of 10
characters including reported or implied places for cents (implied value of 00 after
the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.

A.1.3.1.3

Identifier
An identifier data element always contains a value from a predefined list of codes
that is maintained by the ASC X12 Committee or some other body recognized by
the Committee. Trailing spaces should be suppressed unless they are necessary
to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is “ID.”

A.1.3.1.4

String
A string data element is a sequence of any characters from the basic or extended
character sets. The significant characters shall be left justified. Leading spaces,
when they occur, are presumed to be significant characters. Trailing spaces
should be suppressed unless they are necessary to satisfy a minimum length.
The representation for this data element type is “AN.”

A.1.3.1.5

Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is
the last two digits of the calendar year, MM is the month (01 to 12), and DD is the
day in the month (01 to 31). The representation for this data element type is “DT.”
Users of this guide should note that all dates within transactions are 8-character
dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA
segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.

A.1.3.1.6

Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00
to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is “TM.” The length of the data element determines the format of the transmitted time.
EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data
elements of six characters denote HHMMSS.

Original Page Number A.6 dated May 2000

OCTOBER 2002

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
FUNCTIONAL GROUP HEADER
GS

004010X095A1 • 834 • GS
FUNCTIONAL GROUP HEADER

004010X095A1GROUP
FUNCTIONAL
GS
• 002 • HEADER

IMPLEMENTATION

FUNCTIONAL GROUP HEADER
Example: GS✽BE✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X095A1~

005
100
4

Changed example

STANDARD

GS Functional Group Header
Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM

GS01

GS ✽

479

Functional
ID Code
M

GS07

GS02

2/2

455

GS08

✽ Responsible ✽
Agency Code
M

1/2

142

GS03

✽ Application ✽
Send’s Code
AN 2/15

GS04

✽

AN 2/15

373

Date
M

GS05

✽
8/8

337

Time
M

GS06

✽
4/8

Group Ctrl
Number
M

1/9

480

Ver/Release
ID Code
M

124

Application
Rec’s Code

AN 1/12

ELEMENT SUMMARY

USAGE

REQUIRED

REF.
DES.

GS01

DATA
ELEMENT

479

NAME

ATTRIBUTES

Functional Identifier Code

2/2

Code identifying a group of application related transaction sets
CODE

BE
REQUIRED

GS02

142

DEFINITION

Benefit Enrollment and Maintenance (834)

Application Sender’s Code

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

1000009
REQUIRED

GS03

124

Application Receiver’s Code

2/15

Code identifying party receiving transmission. Codes agreed to by trading partners

Use this code to identify the unit receiving the information.

1000010
REQUIRED

GS04

373

Date

8/8

4/8

Date expressed as CCYYMMDD
SEMANTIC:

Use this date for the functional group creation date.

1000011
REQUIRED

GS04 is the group date.

GS05

337

Time

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or
HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =
integer seconds (00-59) and DD = decimal seconds; decimal seconds are
expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC:

1000012

OCTOBER 2002

GS05 is the group time.

Use this time for the creation time. The recommended format is
HHMM.

Original Page Number B.8 dated May 2000

004010X095A1 • 834 • GS
FUNCTIONAL GROUP HEADER

REQUIRED

GS06

ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE

Group Control Number

1/9

Assigned number originated and maintained by the sender
The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.

SEMANTIC:

REQUIRED

GS07

455

Responsible Agency Code

1/2

Code used in conjunction with Data Element 480 to identify the issuer of the
standard
CODE

X
REQUIRED

GS08

480

DEFINITION

Accredited Standards Committee X12

Version / Release / Industry Identifier Code

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI
standard being used, including the GS and GE segments; if code in DE455 in GS
segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6
are the release and subrelease, level of the version; and positions 7-12 are the
industry or trade association identifiers (optionally assigned by user); if code in
DE455 in GS segment is T, then other formats are allowed
CODE

New code value

004010X095A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.

1091

DEFINITION

Original Page Number B.9 dated May 2000

When using the X12N Benefit Enrollment and
Maintenance Implementation Guide, originally
published May 2000 as 004010X095 and
incorporating the changes identified in the Addenda,
the value used in GS08 must be “004010X095A1".

OCTOBER 2002

File Type	application/pdf
File Modified	2002-10-31
File Created	2001-08-31