Schedule H - 834 Example Final.txt

2 KB Posted

Attached to
HMO Services for MPSERS
Solicitation number
RFP-171-190000002803-2
Issued by
Michigan

About this file

Written by GovTribe AI ·

This document is an 834 Electronic Data Interchange (EDI) file from the Michigan Office of Retirement Services, specifically related to health insurance enrollment and coordination of benefits for multiple individuals. The file appears to be a data transmission detailing health insurance coverage and Medicare coordination for three individuals: Jane Doe, Katie Perry, and Joe Smith. The file contains detailed enrollment information, including personal identifiers, contact details, demographic information, health plan codes, and coverage effective dates spanning from 1998 to 2013.

The file includes multiple reference numbers and tracking codes, with specific health plan types noted as HLT (Health) with variants like SPO (Specific Provider Option) and ESP (Essential Services Plan). Each individual's record contains multiple data segments tracking insurance status, Medicare Part A and Part B coordination, and various effective and termination dates. The transmission seems to be a standardized electronic file used for health insurance enrollment and benefits tracking, likely for state employee or retirement system health coverage management, with precise date-specific tracking of individual enrollment and coverage changes.

Text of this file

Request For Proposal No.

Schedule H 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~

Other files

File Type Posted
RFP 190000002803 - Questions and Answers.pdf PDF
Schedule D - Definitions.docx DOCX document
Schedule F - PPO Summary of Benefits_Medicare Advantage.pdf PDF
Schedule F - PPO Summary of Benefits_nonMedicare.pdf PDF
Standard Contract Terms - Revised with Redlines 7-31-19.docx DOCX document
Schedule B - Pricing.xlsx XLSX spreadsheet
Schedule E - Account Management Satisfaction Survey.doc DOC document
Schedule M - 2019 MSPERS Pharmacy Summary of Benefits_Medicare.pdf PDF
Standard Contract Terms.docx DOCX document
Non-Disclosure-Agreement.docx DOCX document
Schedule G - Dependent Coverage.pdf PDF
Schedule H2 - 834 Use Case.docx DOCX document
Proposal Instructions-Confidential-Treatment-Vendor-Questions-Worksheet.docx DOCX document
Schedule A - Statement of Work - Revised with Redlines 7-31-19.docx DOCX document
Schedule A - Statement of Work.docx DOCX document
Schedule C - Mandatory Requirements Form.doc DOC document
Schedule I - Medical Claim Layout.xlsx XLSX spreadsheet
Schedule J - Benefit Comparison, Actuarial Attestation.xlsx XLSX spreadsheet
Schedule M - 2019 MPSERS Pharmacy Summary of Benefits_Non Medicare.pdf PDF
Show all 19

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