Schedule F1 834 Example.docx

16 KB Posted

Attached to
MPSERS Dental Benefit Plan Administration
Solicitation number
RFP 171 200000001290 3
Issued by
Michigan

About this file

Written by GovTribe AI ·

This file is a Schedule F1 834 Example document related to Michigan State RFP No. 200000001290, formatted as an EDI 834 Health Plan Enrollment and Maintenance transaction file. The document serves as a sample submission from the Michigan Office of Retirement Services (Submitter ID: 386000134) containing health insurance enrollment and coverage information. The file structure demonstrates the standard EDI 834 format used for transmitting health plan enrollment data, with a transmission date of May 4, 2012, at 23:59 hours, using the X12 005010X220A1 standard.

The file contains multiple member enrollment records with associated health coverage details. Included are enrollment records for five individuals—Jane Doe, John Doe, Katie Perry, and Joe Smith—each with personal identifiers, addresses in Michigan locations including Bellevue, Saline, Grand Blanc, and Lansing, and coverage information including health insurance plan identifiers, coverage effective dates, and coordination of benefits (COB) information related to Medicare Part A and Part B plans. The records show various coverage types including health plans with different plan codes (021, 001, 024) and coverage effective dates ranging from April 2008 through December 2013. This document exemplifies the data structure and format required for state and local health insurance enrollment submissions and serves as a reference template for vendors preparing EDI 834 transactions for the Michigan Office of Retirement Services.

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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~

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