forked from Inteligenz/X12Parser
-
Notifications
You must be signed in to change notification settings - Fork 16
834 Sample X12 XML
Brad Van Fleet edited this page Aug 20, 2018
·
2 revisions
<?xml version="1.0"?>
<Interchange>
<ISA>
<!--Author Information Qualifier-->
<ISA01>00<!--No Authorization Information Present--></ISA01>
<!--Author Information-->
<ISA02> </ISA02>
<!--Security Information Qualifer-->
<ISA03>00<!--No Security Information Present--></ISA03>
<!--Security Information-->
<ISA04> </ISA04>
<!--Interchange ID Qualifier-->
<ISA05>01<!--Duns (Dun & Bradstreet)--></ISA05>
<!--Interchange Sender ID-->
<ISA06>9012345720000 </ISA06>
<!--Interchange ID Qualifier-->
<ISA07>01<!--Duns (Dun & Bradstreet)--></ISA07>
<!--Interchange Receiver ID-->
<ISA08>9088877320000 </ISA08>
<!--Interchange Date-->
<ISA09>020816</ISA09>
<!--Interchange Time-->
<ISA10>1144</ISA10>
<!--Inter Control Standards Identifier-->
<ISA11>U<!--U.S. EDI Community of ASC X12, TDCC, and UCS--></ISA11>
<!--Inter Control Version Number-->
<ISA12>00401</ISA12>
<!--Inter Control Number-->
<ISA13>000000031</ISA13>
<!--Acknowlegment Requested-->
<ISA14>1<!--Interchange Acknowledgment Requested--></ISA14>
<!--Usage Indicator-->
<ISA15>T<!--Test Data--></ISA15>
<!--Component Element Separator-->
<ISA16>
<ISA1601 />
<ISA1602 />
</ISA16>
</ISA>
<FunctionGroup>
<GS>
<!--Functional Identifier Code-->
<GS01>BE<!--Benefit Enrollment--></GS01>
<!--Application Sender's Code-->
<GS02>901234572000</GS02>
<!--Application Receiver's Code-->
<GS03>908887732000</GS03>
<!--Date-->
<GS04>20070816</GS04>
<!--Time-->
<GS05>1615</GS05>
<!--Group Control Number-->
<GS06>31</GS06>
<!--Responsible Agency Code-->
<GS07>X<!--Accredited Standards Committee X12--></GS07>
<!--Version/Release/Industry Identifier Code-->
<GS08>004010X096A1</GS08>
</GS>
<Transaction ControlNumber="12345">
<ST>
<!--Transaction Set Identifier Code-->
<ST01>834</ST01>
<!--Transaction Set Control Number-->
<ST02>12345</ST02>
</ST>
<BGN>
<!--Transaction Set Purpose Code-->
<BGN01>00<!--Original--></BGN01>
<!--Reference Identification-->
<BGN02>123456</BGN02>
<!--Date-->
<BGN03>19980502</BGN03>
<!--Time-->
<BGN04>1200</BGN04>
<BGN05 />
<BGN06 />
<BGN07 />
<!--Action Code-->
<BGN08>2<!--Change (Update)--></BGN08>
</BGN>
<Loop LoopId="1000A" Name="SPONSOR NAME">
<N1>
<!--Entity Identifier Code-->
<N101>P5<!--Plan Sponsor--></N101>
<N102 />
<!--Identification Code Qualifier-->
<N103>FI<!--Federal Taxpayer's Identification Number--></N103>
<!--Identification Code-->
<N104>999888777</N104>
</N1>
</Loop>
<Loop LoopId="1000B" Name="PAYER">
<N1>
<!--Entity Identifier Code-->
<N101>IN<!--Insurer--></N101>
<N102 />
<!--Identification Code Qualifier-->
<N103>FI<!--Federal Taxpayer's Identification Number--></N103>
<!--Identification Code-->
<N104>654456654</N104>
</N1>
</Loop>
<Loop LoopId="2000" Name="MEMBER LEVEL DETAIL">
<INS>
<!--Insured Indicator-->
<INS01>Y<!--Yes--></INS01>
<!--Individual Relationship Code-->
<INS02>18<!--Self--></INS02>
<!--Maintenance Type Code-->
<INS03>021<!--Addition--></INS03>
<!--Maintenance Reason Code-->
<INS04>20<!--Active--></INS04>
<!--Benefit Status Code-->
<INS05>A<!--Active--></INS05>
<INS06 />
<INS07 />
<!--Employment Status Code-->
<INS08>FT<!--Full-time active employee--></INS08>
</INS>
<REF>
<!--Reference Identification Qualifier-->
<REF01>0F<!--Subscriber Number--></REF01>
<!--Reference Identification-->
<REF02>123456789</REF02>
</REF>
<REF>
<!--Reference Identification Qualifier-->
<REF01>1L<!--Group or Policy Number--></REF01>
<!--Reference Identification-->
<REF02>123456001</REF02>
</REF>
<DTP>
<!--Data/Time Qualifier-->
<DTP01>356<!--Eligibility Begin--></DTP01>
<!--Date Time Period Format Qualifier-->
<DTP02>D8<!--Date Expression in Format CCYYMMDD--></DTP02>
<!--Date Time Period-->
<DTP03>19960523</DTP03>
</DTP>
<Loop LoopId="2100A" Name="MEMBER NAME">
<NM1>
<!--Entity Identifier Code-->
<NM101>IL<!--Insured or Subscriber--></NM101>
<!--Entity Type Qualifier-->
<NM102>1<!--Person--></NM102>
<!--Name Last or Organization Name-->
<NM103>DOE</NM103>
<!--Name First-->
<NM104>JOHN</NM104>
<!--Name Middle-->
<NM105>P</NM105>
<NM106 />
<NM107 />
<!--Identification Code Qualifier-->
<NM108>34<!--Social Security Number--></NM108>
<!--Identification Code-->
<NM109>123456789</NM109>
</NM1>
<PER>
<!--Contact Function Code-->
<PER01>IP<!--Insured Party--></PER01>
<PER02 />
<!--Communication Number Qualifier-->
<PER03>HP<!--Home Phone Number--></PER03>
<!--Communication Number-->
<PER04>7172343334</PER04>
<!--Communication Number Qualifier-->
<PER05>WP<!--Work Phone Number--></PER05>
<!--Communication Number-->
<PER06>7172341240</PER06>
</PER>
<N3>
<!--Address Information-->
<N301>100 MARKET ST</N301>
<!--Address Information-->
<N302>APT 3G</N302>
</N3>
<N4>
<!--City Name-->
<N401>CAMP HILL</N401>
<!--State or Provice Code-->
<N402>PA</N402>
<!--Postal Code-->
<N403>17011</N403>
<N404 />
<!--Location Qualifier-->
<N405>CY<!--County/Parish--></N405>
<!--Location Identifier-->
<N406>CUMBERLAND</N406>
</N4>
<DMG>
<!--Date Time Period Format Qualifier-->
<DMG01>D8<!--Date Expressed in Format CCYYMMDD--></DMG01>
<!--Date Time Period-->
<DMG02>19400816</DMG02>
<!--Gender Code-->
<DMG03>M<!--Male--></DMG03>
</DMG>
</Loop>
<Loop LoopId="2300" Name="HEALTH COVERAGE">
<HD>
<!--Maintenance Type Code-->
<HD01>021<!--Addition--></HD01>
<HD02 />
<!--Insurance Line Code-->
<HD03>HLT<!--Health--></HD03>
</HD>
<DTP>
<!--Data/Time Qualifier-->
<DTP01>348</DTP01>
<!--Date Time Period Format Qualifier-->
<DTP02>D8<!--Date Expression in Format CCYYMMDD--></DTP02>
<!--Date Time Period-->
<DTP03>19960601</DTP03>
</DTP>
<Loop LoopId="2320" Name="COORDINATION OF BENEFITS">
<COB>
<!--Payer Responsibility Sequence Number Code-->
<COB01>P<!--Primary--></COB01>
<!--Reference Identification-->
<COB02>890111</COB02>
<!--Coordination of Benefits Code-->
<COB03>5<!--Unknown--></COB03>
</COB>
<N1>
<!--Entity Identifier Code-->
<N101>IN<!--Insurer--></N101>
<!--Name-->
<N102>ABC INSURANCE CO</N102>
</N1>
</Loop>
</Loop>
<Loop LoopId="2300" Name="HEALTH COVERAGE">
<HD>
<!--Maintenance Type Code-->
<HD01>021<!--Addition--></HD01>
<HD02 />
<!--Insurance Line Code-->
<HD03>DEN<!--Dental--></HD03>
</HD>
<DTP>
<!--Data/Time Qualifier-->
<DTP01>348</DTP01>
<!--Date Time Period Format Qualifier-->
<DTP02>D8<!--Date Expression in Format CCYYMMDD--></DTP02>
<!--Date Time Period-->
<DTP03>19960601</DTP03>
</DTP>
</Loop>
<Loop LoopId="2300" Name="HEALTH COVERAGE">
<HD>
<!--Maintenance Type Code-->
<HD01>021<!--Addition--></HD01>
<HD02 />
<!--Insurance Line Code-->
<HD03>VIS<!--Vision--></HD03>
</HD>
<DTP>
<!--Data/Time Qualifier-->
<DTP01>348</DTP01>
<!--Date Time Period Format Qualifier-->
<DTP02>D8<!--Date Expression in Format CCYYMMDD--></DTP02>
<!--Date Time Period-->
<DTP03>19960601</DTP03>
</DTP>
</Loop>
</Loop>
<SE>
<SE01>22</SE01>
<SE02>12345</SE02>
</SE>
</Transaction>
<GE>
<!--Number of Transaction Sets Included-->
<GE01>1</GE01>
<!--Group Control Number-->
<GE02>31</GE02>
</GE>
</FunctionGroup>
<IEA>
<!--Number of Included Functional Groups-->
<IEA01>1</IEA01>
<!--Interchange Control Number-->
<IEA02>000000031</IEA02>
</IEA>
</Interchange>