Schedule F1 834 Example.docx

16 KB Posted

Attached to
MPSERS Dental Benefit Plan Administration
Solicitation number
RFP-171-200000001290-3
Issued by
Grand Traverse County, Lansing City, Michigan

About this file

Written by GovTribe AI ·

This is an 834 Benefit Enrollment and Maintenance EDI (Electronic Data Interchange) transaction file example from the Michigan Office of Retirement Services (ORS). The file demonstrates the standard format for transmitting enrollment and demographic information for healthcare benefits, including examples of multiple beneficiaries with different coverage types and Medicare coordination.

The file contains detailed member information including names, addresses, social security numbers, dates of birth, and benefit coverage details for several individuals including Jane Doe, John Doe, Katie Perry, and Joe Smith Jr. The data includes specific enrollment dates, Medicare coordination information for Parts A and B, and various identification numbers used for benefit administration. All examples show Michigan residents with different coverage effective dates ranging from 1998 to 2013, demonstrating various scenarios of health benefit enrollment and Medicare coordination.

View the file

Other files

File Type Posted
Proposal Instructions - Confidential Treatment - Vendor Questions Worksheet.docx DOCX document
Schedule A Statement of WorkREVISED.docx DOCX document
Schedule I Account Management Satisfaction Survey.doc DOC document
Schedule K Policy Appeals Processes.docx DOCX document
Schedule N Definitions.docx DOCX document
Schedule B Pricing.xlsx XLSX spreadsheet
Schedule F2 834 Use Case.docx DOCX document
Schedule G Generic Medical Claim Layout.xlsx XLSX spreadsheet
Schedule S Enrollment Data.xlsx XLSX spreadsheet
Schedule E Data Security Requirements REVISED2.docx DOCX document
Schedule H Service Level Agreements.xlsx XLSX spreadsheet
Schedule P - HIPAA Business Associate Agreement.docx DOCX document
Standard Contract Terms.docx DOCX document
Schedule D Contractor Hosted Software and Terms.docx DOCX document
Schedule J Plan Design with Procedure Codes.xlsx XLSX spreadsheet
Schedule L Coordination of Benefits.docx DOCX document
Schedule M Service Availability Report.docx DOCX document
Schedule O Contractors Disaster Recovery Plan.docx DOCX document
Schedule Q GeoAccess.xlsx XLSX spreadsheet
Show all 19

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

STATE OF MICHIGAN

RFP No. 200000001290

SCHEDULE F1

834 Example

ISA*00* *00* *30*386000134 *30*<Vendor Tax ID#> *120504*2359*^*00501*000000001*0*P*:~ GS*BE*386000134*<Vendor Tax ID#>*20120504*2359*1*X*005010X220A1~

ST*834*0235*005010X220A1~

BGN*00*235*20120504*2359****2~

DTP*007*D8*20120504~

N1*P5*MICHIGAN OFFICE OF RETIREMENT SERVICES*FI*386000134~

N1*IN*<Vendor Name>*FI*<Vendor Tax ID#>~

INS*Y*18*021*28*A*E**RT*N*N~

REF*0F*123456789~

REF*6O*123456789~

REF*ZZ*2&MIPG&20040501~

REF*F6*123456789A~

DTP*286*D8*20040501~

DTP*356*D8*20120701~

NM1*IL*1*DOE*JANE*L***34*123456789~

PER*IP**HP*1234567890~

N3*123 FIRST ST~

N4*BELLEVUE*MI*49021~

DMG*D8*19500101*F~

HD*021**HLT**SPO~

DTP*348*D8*20120701~

INS*Y*18*001*43*A*C**RT*N*N~

REF*0F*987654321~

REF*6O*987654321~

REF*ZZ*2&MIPG&19980701~

REF*F6*987654321A~

DTP*286*D8*19980701~

DTP*356*D8*20080401~

DTP*338*D8*20080401~

DTP*338*D8*20080401~

NM1*IL*1*DOE*JOHN*H***34*987654321~

PER*IP**HP*1234567890~

N3*111 MAIN ST~

N4*SALINE*MI*48176~

DMG*D8*19450401*M~

HD*001**HLT**ESP~

DTP*303*D8*20120501~

COB*P*987654321A*1~

DTP*344*D8*20080424~

NM1*IN*2*MEDICARE PART A~

COB*P*987654321A*1~

DTP*344*D8*20080424~

NM1*IN*2*MEDICARE PART B~

INS*Y*18*001*29*A*C**RT*N*N~

REF*0F*123456789~

REF*6O*123456789~

REF*ZZ*2&MIPG&19990801~

REF*F6*123456789A~

DTP*286*D8*19990801~

DTP*356*D8*20131201~

DTP*338*D8*20131201~

DTP*338*D8*20131201~

NM1*IL*1*PERRY*KATIE*W***34*123456789~

PER*IP**HP*6164539312~

N3*987 FRONT ST~

N4*GRAND BLANC*MI*49534~

DMG*D8*19481212*M~

HD*001**HLT**ESP~

DTP*303*D8*20131201~

COB*P*123456789A*1~

DTP*344*D8*20131201~

NM1*IN*2*MEDICARE PART A~

COB*P*123456789A*1~

DTP*344*D8*20131201~

NM1*IN*2*MEDICARE PART B~

INS*Y*18*024*07*A*C**TE*N*N~

REF*0F*987654321~

REF*6O*987654321~

REF*ZZ*2&BASC&20100701~

REF*F6*162406896A~

DTP*286*D8*20100701~

DTP*356*D8*20130831~

DTP*338*D8*20130501~

DTP*338*D8*20130501~

NM1*IL*1*SMITH*JOE*M**JR*34*987654321~

PER*IP**HP*1234567890~

N3*9999 TEST DRIVE~

N4*LANSING*MI*48075~

DMG*D8*19480523*M~

HD*024**HLT**ESP~

DTP*349*D8*20130831~

COB*P*987654321A*1~

DTP*344*D8*20130501~

NM1*IN*2*MEDICARE PART A~

COB*P*9876543216A*1~

DTP*344*D8*20130501~

NM1*IN*2*MEDICARE PART B~

SE*86*0235~

GE*1*1~

IEA*1*000000001~

File details come from the government source that posted it. Updated .