NRPM: Standards for Electronic Transactions. ADDENDUM 5--BENEFIT ENROLLMENT AND MAINTENANCE

05/07/1998

[Direct Comments to Judy Ball, Enrollment and Eligibility IT]

[Please label any written comments or e-mailed comments about this section with the subject: Addendum 5]

The transaction selected for benefit enrollment and maintenance is ASC X12N 834 - Benefit Enrollment and Maintenance Transaction Set (004010X095).

A. Implementation Guide and Source

The source of the implementation guide for the benefit enrollment and maintenance transaction set is: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878, Telephone 301-590-9337, FAX: 301-869-9460. The web site address is http://www.wpc-edi.com/hipaa/

B. Data Elements

Label - name of elements

Account Address Information

Account City Name

Account Communication Number

Account Contact Inquiry Reference Number

Account Contact Name

Account Country Code

Account Effective Date

Account Identification Code

Account Monetary Amount

Account Number Qualifier

Account Postal ZIP Code

Account State Code

Action Code

Additional Account Identifier

Additional Other Coverage Identifier

Adjustment Amount

Adjustment Reason Code Characteristic

Adjustment Reason Code

Amount Qualifier Code

Assigned Number

Benefit Account Number

Benefit Status Code

Birth Sequence Number

Card Count

Citizenship Status Code

Code List Qualifier Code

Communication Number Qualifier

Communication Number

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Qualifying Event Code

Contact Function Code

Contact Inquiry Reference

Coordination of Benefits Code

Coordination of Benefits Date

Country Code

Coverage Level Code

Creation Date

Credit/Debit Flag Code

Current Health Condition Code

Date Time Period Format Qualifier

Date/Time Qualifier

Dependent Employer Identification Code

Dependent Employer Name

Dependent Employment Date

Dependent School Date

Dependent School Identification Code

Dependent School Name

Description Text

Diagnosis Code

Disability Eligibility Date

Disability Maximum Entitlement Amount

Disability Type Code

Employment Status Code

Enrollment Control Total

Entity Identifier Code

Entity Relationship Code

Entity Type Qualifier

File Creation Time

First Diagnosed Date

Frequency Code

Gender Code

Group or Policy Number

Health Coverage Eligibility Date

Health-Related Code

Identification Card Type Code

Identification Code Qualifier

Individual Relationship Code

Industry Code

Insurance Eligibility Date

Insurance Group Number

Insurance Line Code

Insurer Contact Inquiry Reference

Insurer Contact Name

Insurer Contact Number

Insurer Entity Relationship Code

Insurer Identification Code

Insurer Name

Issuing State

Last Visit Reason Text

Late Reason Code

Location Qualifier

Maintenance Reason Code

Maintenance Type Code

Marital Status Code

Master Policy Number

Medicare Plan Code

Member Additional Address

Member City Name

Member Contact Name

Member Postal Code

Member State or Province Code

Monetary Amount

Occupation Code

Other Insurance Company Identification Code

Other Insurance Company Name

Payer Responsibility Sequence Number Code

Plan Coverage Description Text

Policy Name

Pre-disability Work Days Count

Premium Contribution Amount

Previous Transaction Identifier

Primary Insured Collateral Dependent Count

Primary Insured Sponsored Dependent Count

Product Option Code

Product/Service ID Qualifier

Provider Code

Provider Communications Number

Provider Contact Inquiry Reference

Provider Contact Name

Provider Eligibility Date

Provider First Name

Provider Identifier

Provider Last or Organization Name

Provider Middle Name

Provider Name Prefix

Provider Name Suffix

Quantity Count

Quantity Qualifier

Race or Ethnicity Code

Reference Identification Qualifier

Sponsor Additional Name

Sponsor City Name

Sponsor Contact Name

Sponsor Country Code

Sponsor Identifier

Sponsor Name

Sponsor State Code

Sponsor Street Address

Sponsor Zip Code

Student Status Code

Subscriber or Dependent Death Date

Subscriber Additional Identifier

Subscriber Birth Date

Subscriber City

Subscriber County Code

Subscriber Current Weight

Subscriber First Address Line

Subscriber First Name

Subscriber Height

Subscriber Identifier

Subscriber Last Name

Subscriber Middle Name

Subscriber Name Prefix

Subscriber Name Suffix

Subscriber Postal ZIP Code

Subscriber Previous Weight

Subscriber Second Address Line

Subscriber State

Time Zone Code

Transaction Segment Count

Transaction Set Control Number

Transaction Set Identifier Code

Transaction Set Purpose Code

TPA or Broker Account Address

TPA or Broker Account Amount

TPA or Broker Account City Name

TPA or Broker Account Contact Communication Number

TPA or Broker Account Contact Inquiry Reference

TPA or Broker Account Contact Name

TPA or Broker Account Number

TPA or Broker Account Postal Code

TPA or Broker Account State or Province Code

TPA or Broker Additional Account Reference Identification Number

TPA or Broker Additional Name

TPA or Broker Communication Number

TPA or Broker Contact Inquiry Reference Number

TPA or Broker Country Code

TPA or Broker Identification Code

TPA or Broker Name

TPA or Broker State Code

Underwriting Decision Code

Version Identification Code

Weight Change Text

Work Intensity Code

Yes/No Condition or Response Code