EDI 834 Data Transformation Documentation

EDI 834 Data Transformation

Create and transform EDI messages using the JSON format of the EDI.

Our current supported EDI version: 005010

Need help with some of our documentation? Feel free to contact our support team, and one of our support team members will be happy to assist you.

EDI 834 Request to JSON Response

Transforms an EDI 834 message into JSON.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/edi834-to-json

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request

EDI 834 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*HS*SENDER CODE*RECEIVER CODE*20220412*1513*002*X*005010X220A1~ST*834*0001*005010X220A1~BGN*00*12456*19980520*1200****2~N1*P5**FI*999888777~N1*IN**FI*654456654~INS*Y*18*021*20*A***FT~REF*0F*123456789~REF*1L*123456001~DTP*356*D8*19960523~NM1*IL*1*DOE*JOHN*P***34*123456789~PER*IP**HP*7172343334*WP*7172341240~N3*100 MARKET ST*APT 3G~N4*CAMP HILL*PA*17011**CY*CUMBERLAND~DMG*D8*19400816*M~HD*021**HLT~DTP*348*D8*19960601~COB*P*890111*5~HD*021**DEN~DTP*348*D8*19960601~HD*021**VIS~DTP*48*D8*19960601~SE*21*12345~GE*1*002~IEA*1*000000001~

Sample response

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HS",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER CODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "002",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X220A1"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "834",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X220A1"
          },
          "BeginningSegment": {
            "BGN_01_TransactionSetPurposeCode_ID": "00",
            "BGN_02_ReferenceIdentification_AN": "12456",
            "BGN_03_Date_DT": "19980520",
            "BGN_04_Time_TM": "1200",
            "BGN_05_TimeCode_ID": null,
            "BGN_06_ReferenceIdentification_AN": null,
            "BGN_07_TransactionTypeCode_ID": null,
            "BGN_08_ActionCode_ID": "2",
            "BGN_09_SecurityLevelCode_ID": null
          },
          "TransactionSetPolicyNumber": null,
          "FileEffectiveDate": null,
          "TransactionSetControlTotals": null,
          "SponsorName_Loop_1000A": {
            "SponsorName": {
              "N1_01_EntityIdentifierCode_ID": "P5",
              "N1_02_Name_AN": null,
              "N1_03_IdentificationCodeQualifier_ID": "FI",
              "N1_04_IdentificationCode_AN": "999888777",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            }
          },
          "Payer_Loop_1000B": {
            "Payer": {
              "N1_01_EntityIdentifierCode_ID": "IN",
              "N1_02_Name_AN": null,
              "N1_03_IdentificationCodeQualifier_ID": "FI",
              "N1_04_IdentificationCode_AN": "654456654",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            }
          },
          "TPABrokerName_Loop_1000C": [
            {
              "TPABrokerName": null,
              "TPABrokerAccountInformation_Loop_1100C": {
                "TPABrokerName": null
              }
            }
          ],
          "MemberLevelDetail_Loop_2000": [
            {
              "MemberLevelDetail": {
                "INS_01_YesNoConditionOrResponseCode_ID": "Y",
                "INS_02_IndividualRelationshipCode_ID": "18",
                "INS_03_MaintenanceTypeCode_ID": "021",
                "INS_04_MaintenanceReasonCode_ID": "20",
                "INS_05_BenefitStatusCode_ID": "A",
                "INS_06_MedicareStatusCode": null,
                "INS_07_ConsolidatedOmnibusBudgetReconciliationActQualifying_ID": null,
                "INS_08_EmploymentStatusCode_ID": "FT",
                "INS_09_StudentStatusCode_ID": null,
                "INS_10_YesNoConditionOrResponseCode_ID": null,
                "INS_11_DateTimePeriodFormatQualifier_ID": null,
                "INS_12_DateTimePeriod_AN": null,
                "INS_13_ConfidentialityCode_ID": null,
                "INS_14_CityName_AN": null,
                "INS_15_StateOrProvinceCode_ID": null,
                "INS_16_CountryCode_ID": null,
                "INS_17_Number_N": null
              },
              "SubscriberIdentifier": {
                "REF_01_ReferenceIdentificationQualifier_ID": "0F",
                "REF_02_ReferenceIdentification_AN": "123456789",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              },
              "MemberPolicyNumber": {
                "REF_01_ReferenceIdentificationQualifier_ID": "1L",
                "REF_02_ReferenceIdentification_AN": "123456001",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              },
              "SubscriberSupplementalIdentifier": null,
              "MemberLevelDates": [
                {
                  "DTP_01_DateTimeQualifier_ID": "356",
                  "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                  "DTP_03_DateTimePeriod_AN": "19960523"
                }
              ],
              "MemberName_Loop_2100A": {
                "MemberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                  "NM1_04_NameFirst_AN": "JOHN",
                  "NM1_05_NameMiddle_AN": "P",
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "34",
                  "NM1_09_IdentificationCode_AN": "123456789",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "MemberCommunicationsNumbers": {
                  "PER_01_ContactFunctionCode_ID": "IP",
                  "PER_02_Name_AN": null,
                  "PER_03_CommunicationNumberQualifier_ID": "HP",
                  "PER_04_CommunicationNumber_AN": "7172343334",
                  "PER_05_CommunicationNumberQualifier_ID": "WP",
                  "PER_06_CommunicationNumber_AN": "7172341240",
                  "PER_07_CommunicationNumberQualifier_ID": null,
                  "PER_08_CommunicationNumber_AN": null,
                  "PER_09_ContactInquiryReference_AN": null
                },
                "MemberResidenceStreetAddress": {
                  "N3_01_AddressInformation_AN": "100 MARKET ST",
                  "N3_02_AddressInformation_AN": "APT 3G"
                },
                "MemberCityStateZipCode": {
                  "N4_01_CityName_AN": "CAMP HILL",
                  "N4_02_StateOrProvinceCode_ID": "PA",
                  "N4_03_PostalCode_ID": "17011",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": "CY",
                  "N4_06_LocationIdentifier_AN": "CUMBERLAND",
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "MemberDemographics": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19400816",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "EmploymentClass": null,
                "MemberIncome": null,
                "MemberPolicyAmounts": null,
                "MemberHealthInformation": null,
                "MemberLanguage": null
              },
              "IncorrectMemberName_Loop_2100B": {
                "IncorrectMemberName": null,
                "IncorrectMemberDemographics": null
              },
              "MemberMailingAddress_Loop_2100C": {
                "MemberMailingAddress": null,
                "MemberMailStreetAddress": null,
                "MemberMailCityStateZipCode": null
              },
              "MemberEmployer_Loop_2100D": [
                {
                  "MemberEmployer": null,
                  "MemberEmployerCommunicationsNumbers": null,
                  "MemberEmployerStreetAddress": null,
                  "MemberEmployerCityStateZipCode": null
                }
              ],
              "MemberSchool_Loop_2100E": [
                {
                  "MemberSchool": null,
                  "MemberSchoolCommunicationsNumbers": null,
                  "MemberSchoolStreetAddress": null,
                  "MemberSchoolCityStateZipCode": null
                }
              ],
              "CustodialParent_Loop_2100F": {
                "CustodialParent": null,
                "CustodialParentCommunicationsNumbers": null,
                "CustodialParentStreetAddress": null,
                "CustodialParentCityStateZipCode": null
              },
              "ResponsiblePerson_Loop_2100G": [
                {
                  "ResponsiblePerson": null,
                  "ResponsiblePersonCommunicationsNumbers": null,
                  "ResponsiblePersonStreetAddress": null,
                  "ResponsiblePersonCityStateZipCode": null
                }
              ],
              "DropOffLocation_Loop_2100H": {
                "DropOffLocation": null,
                "DropOffLocationStreetAddress": null,
                "DropOffLocationCityStateZipCode": null
              },
              "DisabilityInformation_Loop_2200": [
                {
                  "DisabilityInformation": null,
                  "DisabilityEligibilityDates": null
                }
              ],
              "HealthCoverage_Loop_2300": [
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "HLT",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "348",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": {
                        "COB_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                        "COB_02_ReferenceIdentification_AN": "890111",
                        "COB_03_CoordinationOfBenefitsCode_ID": "5",
                        "COB_04_ServiceTypeCode_ID": null
                      },
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                },
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "DEN",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "348",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": null,
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                },
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "VIS",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "48",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": null,
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                }
              ],
              "AdditionalReportingCategories": null,
              "MemberReportingCategories_Loop_2700": [
                {
                  "MemberReportingCategories": null,
                  "ReportingCategory_Loop_2750": {
                    "ReportingCategory": null,
                    "ReportingCategoryReference": null,
                    "ReportingCategoryDate": null
                  }
                }
              ],
              "AdditionalReportingCategoriesLoopTermination": null
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "21",
            "SE_02_TransactionSetControlNumber_AN": "12345"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "002"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

JSON Request to EDI 834 Response

Transforms JSON into an EDI 834 message.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/json-to-edi834

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HS",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER CODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "002",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X220A1"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "834",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X220A1"
          },
          "BeginningSegment": {
            "BGN_01_TransactionSetPurposeCode_ID": "00",
            "BGN_02_ReferenceIdentification_AN": "12456",
            "BGN_03_Date_DT": "19980520",
            "BGN_04_Time_TM": "1200",
            "BGN_05_TimeCode_ID": null,
            "BGN_06_ReferenceIdentification_AN": null,
            "BGN_07_TransactionTypeCode_ID": null,
            "BGN_08_ActionCode_ID": "2",
            "BGN_09_SecurityLevelCode_ID": null
          },
          "TransactionSetPolicyNumber": null,
          "FileEffectiveDate": null,
          "TransactionSetControlTotals": null,
          "SponsorName_Loop_1000A": {
            "SponsorName": {
              "N1_01_EntityIdentifierCode_ID": "P5",
              "N1_02_Name_AN": null,
              "N1_03_IdentificationCodeQualifier_ID": "FI",
              "N1_04_IdentificationCode_AN": "999888777",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            }
          },
          "Payer_Loop_1000B": {
            "Payer": {
              "N1_01_EntityIdentifierCode_ID": "IN",
              "N1_02_Name_AN": null,
              "N1_03_IdentificationCodeQualifier_ID": "FI",
              "N1_04_IdentificationCode_AN": "654456654",
              "N1_05_EntityRelationshipCode_ID": null,
              "N1_06_EntityIdentifierCode_ID": null
            }
          },
          "TPABrokerName_Loop_1000C": [
            {
              "TPABrokerName": null,
              "TPABrokerAccountInformation_Loop_1100C": {
                "TPABrokerName": null
              }
            }
          ],
          "MemberLevelDetail_Loop_2000": [
            {
              "MemberLevelDetail": {
                "INS_01_YesNoConditionOrResponseCode_ID": "Y",
                "INS_02_IndividualRelationshipCode_ID": "18",
                "INS_03_MaintenanceTypeCode_ID": "021",
                "INS_04_MaintenanceReasonCode_ID": "20",
                "INS_05_BenefitStatusCode_ID": "A",
                "INS_06_MedicareStatusCode": null,
                "INS_07_ConsolidatedOmnibusBudgetReconciliationActQualifying_ID": null,
                "INS_08_EmploymentStatusCode_ID": "FT",
                "INS_09_StudentStatusCode_ID": null,
                "INS_10_YesNoConditionOrResponseCode_ID": null,
                "INS_11_DateTimePeriodFormatQualifier_ID": null,
                "INS_12_DateTimePeriod_AN": null,
                "INS_13_ConfidentialityCode_ID": null,
                "INS_14_CityName_AN": null,
                "INS_15_StateOrProvinceCode_ID": null,
                "INS_16_CountryCode_ID": null,
                "INS_17_Number_N": null
              },
              "SubscriberIdentifier": {
                "REF_01_ReferenceIdentificationQualifier_ID": "0F",
                "REF_02_ReferenceIdentification_AN": "123456789",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              },
              "MemberPolicyNumber": {
                "REF_01_ReferenceIdentificationQualifier_ID": "1L",
                "REF_02_ReferenceIdentification_AN": "123456001",
                "REF_03_Description_AN": null,
                "REF_04_ReferenceIdentifier": null
              },
              "SubscriberSupplementalIdentifier": null,
              "MemberLevelDates": [
                {
                  "DTP_01_DateTimeQualifier_ID": "356",
                  "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                  "DTP_03_DateTimePeriod_AN": "19960523"
                }
              ],
              "MemberName_Loop_2100A": {
                "MemberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                  "NM1_04_NameFirst_AN": "JOHN",
                  "NM1_05_NameMiddle_AN": "P",
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "34",
                  "NM1_09_IdentificationCode_AN": "123456789",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "MemberCommunicationsNumbers": {
                  "PER_01_ContactFunctionCode_ID": "IP",
                  "PER_02_Name_AN": null,
                  "PER_03_CommunicationNumberQualifier_ID": "HP",
                  "PER_04_CommunicationNumber_AN": "7172343334",
                  "PER_05_CommunicationNumberQualifier_ID": "WP",
                  "PER_06_CommunicationNumber_AN": "7172341240",
                  "PER_07_CommunicationNumberQualifier_ID": null,
                  "PER_08_CommunicationNumber_AN": null,
                  "PER_09_ContactInquiryReference_AN": null
                },
                "MemberResidenceStreetAddress": {
                  "N3_01_AddressInformation_AN": "100 MARKET ST",
                  "N3_02_AddressInformation_AN": "APT 3G"
                },
                "MemberCityStateZipCode": {
                  "N4_01_CityName_AN": "CAMP HILL",
                  "N4_02_StateOrProvinceCode_ID": "PA",
                  "N4_03_PostalCode_ID": "17011",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": "CY",
                  "N4_06_LocationIdentifier_AN": "CUMBERLAND",
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "MemberDemographics": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19400816",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "EmploymentClass": null,
                "MemberIncome": null,
                "MemberPolicyAmounts": null,
                "MemberHealthInformation": null,
                "MemberLanguage": null
              },
              "IncorrectMemberName_Loop_2100B": {
                "IncorrectMemberName": null,
                "IncorrectMemberDemographics": null
              },
              "MemberMailingAddress_Loop_2100C": {
                "MemberMailingAddress": null,
                "MemberMailStreetAddress": null,
                "MemberMailCityStateZipCode": null
              },
              "MemberEmployer_Loop_2100D": [
                {
                  "MemberEmployer": null,
                  "MemberEmployerCommunicationsNumbers": null,
                  "MemberEmployerStreetAddress": null,
                  "MemberEmployerCityStateZipCode": null
                }
              ],
              "MemberSchool_Loop_2100E": [
                {
                  "MemberSchool": null,
                  "MemberSchoolCommunicationsNumbers": null,
                  "MemberSchoolStreetAddress": null,
                  "MemberSchoolCityStateZipCode": null
                }
              ],
              "CustodialParent_Loop_2100F": {
                "CustodialParent": null,
                "CustodialParentCommunicationsNumbers": null,
                "CustodialParentStreetAddress": null,
                "CustodialParentCityStateZipCode": null
              },
              "ResponsiblePerson_Loop_2100G": [
                {
                  "ResponsiblePerson": null,
                  "ResponsiblePersonCommunicationsNumbers": null,
                  "ResponsiblePersonStreetAddress": null,
                  "ResponsiblePersonCityStateZipCode": null
                }
              ],
              "DropOffLocation_Loop_2100H": {
                "DropOffLocation": null,
                "DropOffLocationStreetAddress": null,
                "DropOffLocationCityStateZipCode": null
              },
              "DisabilityInformation_Loop_2200": [
                {
                  "DisabilityInformation": null,
                  "DisabilityEligibilityDates": null
                }
              ],
              "HealthCoverage_Loop_2300": [
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "HLT",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "348",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": {
                        "COB_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                        "COB_02_ReferenceIdentification_AN": "890111",
                        "COB_03_CoordinationOfBenefitsCode_ID": "5",
                        "COB_04_ServiceTypeCode_ID": null
                      },
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                },
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "DEN",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "348",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": null,
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                },
                {
                  "HealthCoverage": {
                    "HD_01_MaintenanceTypeCode_ID": "021",
                    "HD_02_MaintenanceReasonCode_ID": null,
                    "HD_03_InsuranceLineCode_ID": "VIS",
                    "HD_04_PlanCoverageDescription_AN": null,
                    "HD_05_CoverageLevelCode_ID": null,
                    "HD_06_Count_N": null,
                    "HD_07_Count_N": null,
                    "HD_08_UnderwritingDecisionCode_ID": null,
                    "HD_09_YesNoConditionOrResponseCode_ID": null,
                    "HD_10_DrugHouseCode_ID": null,
                    "HD_11_YesNoConditionOrResponseCodeAccountNumber_ID": null
                  },
                  "HealthCoverageDates": [
                    {
                      "DTP_01_DateTimeQualifier_ID": "48",
                      "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                      "DTP_03_DateTimePeriod_AN": "19960601"
                    }
                  ],
                  "HealthCoveragePolicy": null,
                  "HealthCoveragePolicyNumber": null,
                  "PriorCoverageMonths": null,
                  "IdentificationCard": null,
                  "ProviderInformation_Loop_2310": [
                    {
                      "ProviderInformation": null,
                      "ProviderName": null,
                      "ProviderAddress": null,
                      "ProviderCityStateZipCode": null,
                      "ProviderCommunicationsNumbers": null,
                      "ProviderChangeReason": null
                    }
                  ],
                  "CoordinationOfBenefits_Loop_2320": [
                    {
                      "CoordinationOfBenefits": null,
                      "AdditionalCoordinationOfBenefitsIdentifiers": null,
                      "CoordinationOfBenefitsEligibilityDate": null,
                      "CoordinationOfBenefitsRelatedEntity_Loop_2330": [
                        {
                          "CoordinationOfBenefitsRelatedEntity": null,
                          "CoordinationOfBenefitsRelatedEntityAddress": null,
                          "CoordinationOfBenefitsOtherInsuranceCompanyCityStateZipCode": null,
                          "AdministrativeCommunicationsContact": null
                        }
                      ]
                    }
                  ]
                }
              ],
              "AdditionalReportingCategories": null,
              "MemberReportingCategories_Loop_2700": [
                {
                  "MemberReportingCategories": null,
                  "ReportingCategory_Loop_2750": {
                    "ReportingCategory": null,
                    "ReportingCategoryReference": null,
                    "ReportingCategoryDate": null
                  }
                }
              ],
              "AdditionalReportingCategoriesLoopTermination": null
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "21",
            "SE_02_TransactionSetControlNumber_AN": "12345"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "002"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample response

EDI 834 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*HS*SENDER CODE*RECEIVER CODE*20220412*1513*002*X*005010X220A1~ST*834*0001*005010X220A1~BGN*00*12456*19980520*1200****2~N1*P5**FI*999888777~N1*IN**FI*654456654~INS*Y*18*021*20*A***FT~REF*0F*123456789~REF*1L*123456001~DTP*356*D8*19960523~NM1*IL*1*DOE*JOHN*P***34*123456789~PER*IP**HP*7172343334*WP*7172341240~N3*100 MARKET ST*APT 3G~N4*CAMP HILL*PA*17011**CY*CUMBERLAND~DMG*D8*19400816*M~HD*021**HLT~DTP*348*D8*19960601~COB*P*890111*5~HD*021**DEN~DTP*348*D8*19960601~HD*021**VIS~DTP*48*D8*19960601~SE*21*12345~GE*1*002~IEA*1*000000001~

Healthcare EDIs

EDI 270 ^SJ (Patient Eligibility Request)

EDI 271 ^SJ (Patient Eligibility Request)

EDI 276 (Claim Status Request)

EDI 277 (Claim Status Response)

EDI 834 (Patient Enrollment)

EDI 835 ^SJ (Claim Payment and Advice)

EDI 837 (Claims)

Acknowledgment EDIs

EDI 997 ^SJ (Functional Acknowledgment)

EDI 999 ^SJ (Implementation Acknowledgment)

Freight and Shipping EDIs

EDI 404 (Rail Carrier Shipment Information)

EDI 410 (Rail Carrier Freight Details and Invoice)