The following is an extract from the Healthcare EDI Fundamentals & Best Practices training course offered by The EDI Academy (http://ediacademy.com/). The EDI Academy offers a two day class just on the topic of healthcare EDI alone which covers all 9 healthcare transactions in detail. This small extract is just one element of the whole course and should not be considered as an EDI tutorial.
834 Your way into process efficiency and error reduction
The 834 Benefit Enrolment transactions is an excellent option for improving the extremely administrative and labour-intensive benefit enrolment process. Most companies do not take advantage of this transaction and manually enrol their employees into benefits. The EDI Academy conducted a survey asking about one hundred attendees throughout the year if they even ever heard of this transaction. Only about 10% heard of it and only about 5% have used it. The companies that use it have gained two significant advantages: significant gain in productivity and a reduction in error rates.
The reason this transaction is easier to implement than other more complicated transactions is because the benefits data such as employee records and plan subscription information is already sitting in the database tables. Since the data is already in the HR system, it’s a matter of extracting it from the HR application and translating to a standard 834 transaction. Most insurance companies welcome this transaction for the obvious process-efficiency reasons as well. The companies that have implemented the 834 typically have more than one insurance carrier that they work with. Since the 834 is a standard HIPAA transaction, the X12 output format varies only with slight nuances. For example, some insurance companies allow dependent-only plans while most do not.
The following is an extract of the 834 tutorial from the Health EDI Training course:
The 834 Benefit Enrollment document is used to provide enrollment information from sponsors to insurance companies. Sponsors are typically corporations or other institutions that provide health care benefits to their employees. The 834 can be used to provide initial enrollment and also provide maintenance (changes, additions, deletions) for existing enrollment. The 834 can be sent from the sponsor to the insurance company or via a third party intermediary.
Some sponsors send the 820 Remittance Advice / EFT document to pay the insurance company. The 270/271 Eligibility Inquiry / Response is sent by the health care provider to the insurance company to request eligibility coverage information.
· Termination date sent at INS level for a subscriber will terminate all coverage for that subscriber and dependent …all subscribers and dependents can be terminated by terminating all insurance products at the HD level
· Termination date sent at INS level for a dependent will terminate coverage for that dependent only not any other dependent or subscriber.
· Termination Date sent at HD level (loop 2300) coverage for that specific insurance product will be terminated from that specific member
· You can terminate all insurance products for the subscriber only and keep insurance for dependents by sending terminating all insurance products for the subscriber at the HD level…this is for “dependent-only plans”
· In case of a transfer from one coverage to another it’s necessary to terminate old coverage and then add new coverage
- BGN-08 has two available action codes:
- “2” for change which includes additions, terminations, and change to current enrollment.
- “4” for verification – this includes full enrollment transaction to verify that sponsor’s and payer’s systems are synchronized.
- A best practice is to send “Change (update transactions)” on a regular basis and conduct “4” for verification periodically to keep the systems in synch.
The following example enrolls an employee into health and dental coverage.
ST*834*1120
BGN*00*1127*20090801*010510****2
REF*38*170175
DTP*382*D8*20090807
N1*P5*XYZ Corporation*FI*953630868
N1*IN*INSURANCE R US*FI*953761231
INS*Y*18*021*20*A***FT
REF*0F*390081234
REF*1L*170805M001
DTP*356*D8*20090807
NM1*IL*1*FLINSTONE*FRED*J***34*390081234
PER*IP**HP*8586790999
N3*123 ANY STREET
N4*SAN DIEGO*CA*92128
DMG*D8*19470611*M
HD*021**HLT
DTP*348*D8*20090807
HD*021**DEN
DTP*348*D8*20090807
SE*20*1120
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Beginning Segment: BGN*00*1127*20090801*010510****2 |
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Transaction Set Purpose Code : Original |
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Reference Identification : 1127 |
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Date : 8/1/2009 |
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Time : 1:05:10 AM |
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Action Code : Change (Update) |
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Reference Identification: REF*38*170175 |
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Master Policy Number : 170175 |
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Date or Time or Period: DTP*382*D8*20090807 |
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Date/Time Qualifier : Enrollment |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20090807 |
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Plan Sponsor: N1*P5*XYZ Corporation*FI*953630868 |
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XYZ Corporation (Federal Taxpayer's Identification Number: 953630868) |
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Insurer: N1*IN*INSURANCE R US*FI*953761231 |
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INSURANCE R US (Federal Taxpayer's Identification Number: 953761231) |
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|
|
|
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Insured Benefit: INS*Y*18*021*20*A***FT |
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Yes/No Condition or Response Code : Yes ('Y' indicates the insured is a subscriber: an 'NO' value would indicate the insured is a dependent.) |
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Individual Relationship Code : Self |
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Maintenance Type Code : Addition |
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Maintenance Reason Code : Active |
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Benefit Status Code : Active |
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Employment Status Code : Full-time |
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Reference Identification: REF*0F*390081234 |
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Subscriber Number : 390081234 (social security number) |
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Group or Policy Number : 170805M001 |
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Date or Time or Period: DTP*356*D8*20090101 |
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Date/Time Qualifier : Eligibility Begin |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20090807 |
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Individual or Organizational Name: NM1*IL*1*FLINSTONE*FRED*J***34*390081234 |
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Entity Identifier Code : Insured or Subscriber |
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Entity Type Qualifier : Person |
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Name Last or Organization Name : FLINSTONE |
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Name First : FRED |
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Name Middle : J |
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Identification Code Qualifier : Social Security Number |
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Identification Code : 390081234 |
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Contact Information: PER*IP**HP*8586790999 |
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Insured Party :
Home Phone Number : 8586790999 |
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Address Information: N3*123 ANY STREET |
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Street : 123 ANY STREET |
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Address Information: N4*SAN DIEGO*CA*92128 |
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City: San Diego STATE: CA ZIP: 92128 |
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Demographic Information: DMG*D8*19470611*M |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 19470611 |
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Gender Code : Male |
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Health Coverage: HD*021**HLT |
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Maintenance Type Code : Addition |
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Insurance Line Code : Health |
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Date or Time or Period: DTP*348*D8*20090101 |
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Date/Time Qualifier : Benefit Begin |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20090807 |
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Health Coverage: HD*021**DEN |
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Maintenance Type Code : Addition |
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Insurance Line Code : Dental |
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Date or Time or Period: DTP*348*D8*20090807 |
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Date/Time Qualifier : Benefit Begin |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20090807 |
The following example is a full file audit sent from a corporation to an insurance company. Although the Implementation Guides do not recommend sending the Full File Audit to perform changes, most insurance companies will accept them as changes if there is mismatch.
For example, an employee that is sent on the 834 full file that is not currently active on the insurance side will generate an add transaction.
ST*834*0001
BGN*00*1*20090801*010510****4
REF*38*170175
DTP*303*D8*20090807
N1*P5*LOONEY TUNES CORP*FI*953630868
N1*IN*INSURANCE R US*FI*953761231
INS*Y*18*030*20*A
REF*0F*390081235
NM1*IL*1*ELMER*FUDD*J***34*390081235
PER*IP**HP*8186790998
N3*3400 Riverside Dr APT. 101
N4*Burbank*CA*91522
DMG*D8*19470611*M
HD*030
DTP*348*D8*20080317
REF*1L*170805M001
INS*Y*18*030*20*A
REF*0F*605681234
NM1*IL*1*BUGS*BUNNY*B***34*605681234
PER*IP**HP*8188242908
N3*3400 Riverside Dr APT. 102
N4*Burbank*CA*91522
DMG*D8*19400727*M
HD*030
DTP*348*D8*20080101
DTP*349*D8*20080813
REF*1L*170805M001
SE*28*0001
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BGN*00*1*20090801*010510****4 |
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Transaction Set Purpose Code : Original |
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Reference Identification : 1 |
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Date : 8/1/2009 |
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Time : 1:05:10 AM |
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Action Code : Verify |
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Reference Identification: REF*38*170175 |
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Master Policy Number : 170175 |
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Date or Time or Period: DTP*303*D8*20090807 |
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Date/Time Qualifier : Maintenance Effective |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20090807 |
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Plan Sponsor: N1*P5*LOONEY TUNES CORP*FI*953630868 |
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LOONEY TUNES CORP (Federal Taxpayer's Identification Number: 953630868) |
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Insurer: N1*IN*INSURANCE R US*FI*953761231 |
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INSURANCE R US (Federal Taxpayer's Identification Number: 953761231) |
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Insured Benefit: INS*Y*18*030*20*A |
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Yes/No Condition or Response Code : Yes ('Y' indicates the insured is a subscriber: an 'NO' value would indicate the insured is a dependent.) |
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Individual Relationship Code : Self |
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Maintenance Type Code : Audit or Compare |
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Maintenance Reason Code : Active |
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Benefit Status Code : Active |
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Reference Identification: REF*0F*390081234 |
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Subscriber Number : 390081234 |
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Individual or Organizational Name: NM1*IL*1*ELMER*FUDD*J***34*390081235 |
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Entity Identifier Code : Insured or Subscriber |
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Entity Type Qualifier : Person |
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Name Last or Organization Name : ELMER |
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Name First : FUDD |
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Name Middle : J |
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Identification Code Qualifier : Social Security Number |
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Identification Code : 390081235 |
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Contact Information: PER*IP**HP*8186790998 |
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Insured Party :
Home Phone Number : 8186790998 |
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Address Information: N3*3400 Riverside Dr APT. 101 |
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Street : 3400 Riverside Dr APT. 101 |
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Address Information: N4*Burbank*CA*91522 |
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CITY: Burbank, STATE: CA ZIP: 91522 |
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Demographic Information: DMG*D8*19470611*M |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 19470611 |
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Gender Code : Male |
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Maintenance Type Code : Audit or Compare |
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Date or Time or Period: DTP*348*D8*20080317 |
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Date/Time Qualifier : Benefit Begin |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20080317 |
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Reference Identification: REF*1L*170805M001 |
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Group or Policy Number : 170805M001 |
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Insured Benefit: INS*Y*18*030*20*A |
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Yes/No Condition or Response Code : Yes ('Y' indicates the insured is a subscriber: an 'NO' value would indicate the insured is a dependent.) |
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Individual Relationship Code : Self |
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Maintenance Type Code : Audit or Compare |
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Maintenance Reason Code : Active |
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Benefit Status Code : Active |
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Reference Identification: REF*0F*605681234 |
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Subscriber Number : 605681234 |
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Individual or Organizational Name: NM1*IL*1*BUGS*BUNNY*B***34*605681234 |
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Entity Identifier Code : Insured or Subscriber |
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Entity Type Qualifier : Person |
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Name Last or Organization Name : BUGS |
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Name First : BUNNY |
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Name Middle : B |
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Identification Code Qualifier : Social Security Number |
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Identification Code : 605681234 |
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Contact Information: PER*IP**HP*8188242908 |
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Insured Party :
Home Phone Number : 8188242908 |
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Address Information: N3*3400 Riverside Dr APT. 102 |
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Street : 3400 Riverside Dr APT. 101 |
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Address Information: N4*Burbank*CA*91522 |
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CITY: Burbank, STATE: CA ZIP: 91522 |
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Demographic Information: DMG*D8*19400727*M |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 19400727 |
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Gender Code : Male |
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Maintenance Type Code : Audit or Compare |
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Date or Time or Period: DTP*348*D8*20080101 |
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Date/Time Qualifier : Benefit Begin |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20080101 |
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Date or Time or Period: DTP*349*D8*20080813 |
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Date/Time Qualifier : Benefit End |
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Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD |
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Date Time Period : 20080813 |
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Reference Identification: REF*1L*170805M001 |
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Group or Policy Number : 170805M001 |
About The EDI Academy
About EDI Academy: Based in Southern, California., EDI Academy was founded by industry professionals who have worked with EDI for more than a decade. They have extensive experience with EDI implementation and have produced successful EDI systems for companies in a wide range of industries. EDI Academy’s instructors are highly knowledgeable professionals who fully understand how and when EDI is needed in today’s marketplace. Popular demand led EDI Academy to begin offering EDI courses to the public in 2007; EDI Academy also hosts EDI seminars and limited-attendance EDI classes for professionals worldwide. For more information about EDI Academy and the range of services the company provides, call (858) 605-0412 or visit www.ediacademy.com
