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 file is an ASC X12 834 Health Plan Enrollment and Maintenance transaction document submitted by the Michigan Office of Retirement Services. The document contains enrollment and benefit information for multiple individuals in health insurance plans administered through the Michigan Insurance Pooling Group (MIPG) and Basic Insurance Services Corporation (BASC). The transaction includes enrollment records for five individuals—Jane Doe, John Doe, Katie Perry, and Joe Smith—with various health coverage types including HLT (Health) plans with different subscriber relationships (SPO for spouse, ESP for employee or self and spouse). The document contains specific plan codes, subscriber IDs, coverage effective dates, and coordination of benefits information with Medicare Part A and Medicare Part B. Coverage effective dates range from 1980 through December 2013, with various plan activation and termination dates specified throughout the transaction.

The file serves as an example 834 transaction in the ASC X12 005010X220A1 format, which is the standard electronic data interchange format used for health insurance enrollment and benefit maintenance communications. This appears to be a reference document or template demonstrating proper formatting and data structure for benefit enrollment submissions, as indicated by the "Example" designation in the filename. No specific pricing terms, contract amounts, set-asides, or procurement response dates are present in this file, as it functions as a technical example of enrollment data transmission rather than a request for proposal with commercial terms.

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~

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