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<?xml version="1.0"?> <ns0:X12_00501_834 xmlns:ns0="http://schemas.microsoft.com/BizTalk/EDI/X12/2006"> - <ST> <ST01_TransactionSetIdentifierCode>834</ST01_TransactionSetIdentifierCode> <ST02_TransactionSetControlNumber>0001</ST02_TransactionSetControlNumber> <ST03_ImplementationConventionReference>005010X220</ST03_ImplementationConventionReference> </ST> - <ns0:BGN_BeginningSegment> <BGN01_TransactionSetPurposeCode>00</BGN01_TransactionSetPurposeCode> <BGN02_TransactionSetReferenceNumber>12345</BGN02_TransactionSetReferenceNumber> <BGN03_TransactionSetCreationDate>20131202</BGN03_TransactionSetCreationDate> <BGN04_TransactionSetCreationTime>1817</BGN04_TransactionSetCreationTime> <BGN05_TimeZoneCode>ET</BGN05_TimeZoneCode> <BGN06_OriginalTransactionSetReferenceNumber>12345</BGN06_OriginalTransactionSetReferenceNumber> <BGN08_ActionCode>2</BGN08_ActionCode> </ns0:BGN_BeginningSegment> - <ns0:REF_TransactionSetPolicyNumber> <REF01_ReferenceIdentificationQualifier>38</REF01_ReferenceIdentificationQualifier> <REF02_MasterPolicyNumber>KHBE2013</REF02_MasterPolicyNumber> </ns0:REF_TransactionSetPolicyNumber> - <ns0:DTP_FileEffectiveDate> <DTP01_DateTimeQualifier>303</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_DateTimePeriod>20131202</DTP03_DateTimePeriod> </ns0:DTP_FileEffectiveDate> - <ns0:QTY_TransactionSetControlTotals> <QTY01_QuantityQualifier>TO</QTY01_QuantityQualifier> <QTY02_RecordTotals>3</QTY02_RecordTotals> </ns0:QTY_TransactionSetControlTotals> - <ns0:QTY_TransactionSetControlTotals> <QTY01_QuantityQualifier>ET</QTY01_QuantityQualifier> <QTY02_RecordTotals>1</QTY02_RecordTotals> </ns0:QTY_TransactionSetControlTotals> - <ns0:QTY_TransactionSetControlTotals> <QTY01_QuantityQualifier>DT</QTY01_QuantityQualifier> <QTY02_RecordTotals>2</QTY02_RecordTotals> </ns0:QTY_TransactionSetControlTotals> - <ns0:N1_SubLoop> - <ns0:TS834_1000A_Loop> - <ns0:N1_SponsorName> <N101_EntityIdentifierCode>P5</N101_EntityIdentifierCode> <N102_PlanSponsorName>John Smith</N102_PlanSponsorName> <N103_IdentificationCodeQualifier>FI</N103_IdentificationCodeQualifier> <N104_SponsorIdentifier>273224444</N104_SponsorIdentifier> </ns0:N1_SponsorName> </ns0:TS834_1000A_Loop> - <ns0:TS834_1000B_Loop> - <ns0:N1_Payer> <N101_EntityIdentifierCode>IN</N101_EntityIdentifierCode> <N102_InsurerName>Health Care Ins</N102_InsurerName> <N103_IdentificationCodeQualifier>FI</N103_IdentificationCodeQualifier> <N104_InsurerIdentificationCode>989929229</N104_InsurerIdentificationCode> </ns0:N1_Payer> </ns0:TS834_1000B_Loop> </ns0:N1_SubLoop> - <ns0:TS834_2000_Loop> - <ns0:INS_MemberLevelDetail> <INS01_MemberIndicator>Y</INS01_MemberIndicator> <INS02_IndividualRelationshipCode>18</INS02_IndividualRelationshipCode> <INS03_MaintenanceTypeCode>028</INS03_MaintenanceTypeCode> <INS04_MaintenanceReasonCode>EC</INS04_MaintenanceReasonCode> <INS05_BenefitStatusCode>A</INS05_BenefitStatusCode> </ns0:INS_MemberLevelDetail> - <ns0:REF_SubLoop> - <ns0:REF_SubscriberIdentifier> <REF01_ReferenceIdentificationQualifier>0F</REF01_ReferenceIdentificationQualifier> <REF02_SubscriberIdentifier>PER12341</REF02_SubscriberIdentifier> </ns0:REF_SubscriberIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>17</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>999999991</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>6O</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>1000000015</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>23</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00123</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier>

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<REF01_ReferenceIdentificationQualifier>ZZ</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00123</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> </ns0:REF_SubLoop> <ns0:DTP_MemberLevelDates> <DTP01_DateTimeQualifier>050</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_StatusInformationEffectiveDate>20131202</DTP03_StatusInformationEffectiveDate> </ns0:DTP_MemberLevelDates> <ns0:DTP_MemberLevelDates> <DTP01_DateTimeQualifier>356</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_StatusInformationEffectiveDate>20140101</DTP03_StatusInformationEffectiveDate> </ns0:DTP_MemberLevelDates> <ns0:NM1_SubLoop> - <ns0:TS834_2100A_Loop> - <ns0:NM1_MemberName> <NM101_EntityIdentifierCode>IL</NM101_EntityIdentifierCode> <NM102_EntityTypeQualifier>1</NM102_EntityTypeQualifier> <NM103_MemberLastName>Smith</NM103_MemberLastName> <NM104_MemberFirstName>John</NM104_MemberFirstName> <NM108_IdentificationCodeQualifier>34</NM108_IdentificationCodeQualifier> <NM109_MemberIdentifier>273224444</NM109_MemberIdentifier> </ns0:NM1_MemberName> - <ns0:PER_MemberCommunicationsNumbers> <PER01_ContactFunctionCode>IP</PER01_ContactFunctionCode> <PER03_CommunicationNumberQualifier>TE</PER03_CommunicationNumberQualifier> <PER04_CommunicationNumber>8593334444</PER04_CommunicationNumber> <PER05_CommunicationNumberQualifier>EM</PER05_CommunicationNumberQualifier> <PER06_CommunicationNumber>john.smith@gmail.com</PER06_CommunicationNumber> </ns0:PER_MemberCommunicationsNumbers> - <ns0:N3_MemberResidenceStreetAddress> <N301_MemberAddressLine>261 Versailles Rd</N301_MemberAddressLine> </ns0:N3_MemberResidenceStreetAddress> - <ns0:N4_MemberCity_State_ZIPCode> <N401_MemberCityName>Frankfort</N401_MemberCityName> <N402_MemberStateCode>KY</N402_MemberStateCode> <N403_MemberPostalZoneorZipCode>40601</N403_MemberPostalZoneorZipCode> <N404_CountryCode>US</N404_CountryCode> <N405_LocationQualifier>CY</N405_LocationQualifier> <N406_LocationIdentifier>Fayette</N406_LocationIdentifier> </ns0:N4_MemberCity_State_ZIPCode> - <ns0:DMG_MemberDemographics> <DMG01_DateTimePeriodFormatQualifier>D8</DMG01_DateTimePeriodFormatQualifier> <DMG02_MemberBirthDate>19690430</DMG02_MemberBirthDate> <DMG03_GenderCode>M</DMG03_GenderCode> <DMG04_MaritalStatusCode>M</DMG04_MaritalStatusCode> - <ns0:C056_CompositeRaceorEthnicityInformation> <C05601_RaceorEthnicityCode>H</C05601_RaceorEthnicityCode> </ns0:C056_CompositeRaceorEthnicityInformation> <DMG06_CitizenshipStatusCode>1</DMG06_CitizenshipStatusCode> </ns0:DMG_MemberDemographics> - <ns0:HLH_MemberHealthInformation> <HLH01_HealthRelatedCode>T</HLH01_HealthRelatedCode> </ns0:HLH_MemberHealthInformation> - <ns0:LUI_MemberLanguage> <LUI01_IdentificationCodeQualifier>LD</LUI01_IdentificationCodeQualifier> <LUI02_LanguageCode>ENG</LUI02_LanguageCode> <LUI04_LanguageUseIndicator>5</LUI04_LanguageUseIndicator> </ns0:LUI_MemberLanguage> - <ns0:LUI_MemberLanguage> <LUI01_IdentificationCodeQualifier>LD</LUI01_IdentificationCodeQualifier> <LUI02_LanguageCode>SPA</LUI02_LanguageCode> <LUI04_LanguageUseIndicator>6</LUI04_LanguageUseIndicator> </ns0:LUI_MemberLanguage> </ns0:TS834_2100A_Loop> </ns0:NM1_SubLoop> <ns0:TS834_2300_Loop> - <ns0:HD_HealthCoverage> <HD01_MaintenanceTypeCode>021</HD01_MaintenanceTypeCode> <HD03_InsuranceLineCode>HLT</HD03_InsuranceLineCode> <HD04_PlanCoverageDescription>Health Care Plus</HD04_PlanCoverageDescription> <HD05_CoverageLevelCode>FAM</HD05_CoverageLevelCode> </ns0:HD_HealthCoverage> - <ns0:DTP_HealthCoverageDates> <DTP01_DateTimeQualifier>348</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_CoveragePeriod>20140101</DTP03_CoveragePeriod> </ns0:DTP_HealthCoverageDates> - <ns0:DTP_HealthCoverageDates> <DTP01_DateTimeQualifier>543</DTP01_DateTimeQualifier>

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<DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_CoveragePeriod>20130202</DTP03_CoveragePeriod> </ns0:DTP_HealthCoverageDates> - <ns0:REF_SubLoop_2> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>CE</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>PLN34567</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>X9</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>ISRPLAN999</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>1L</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>KHBE-I</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> </ns0:REF_SubLoop_2> </ns0:TS834_2300_Loop> - <ns0:TS834_LS_Loop> - <ns0:LS_AdditionalReportingCategories> <LS01_LoopIdentifierCode>2700</LS01_LoopIdentifierCode> </ns0:LS_AdditionalReportingCategories> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>1</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>CSR AMT</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>9V</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>100</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop> </ns0:TS834_2700_Loop> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>2</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>APTC AMT</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>9V</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>100</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop> </ns0:TS834_2700_Loop> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>3</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>PRE AMT TOTAL</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>9X</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>1200</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop>

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</ns0:TS834_2700_Loop> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>4</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>TOT RES AMT</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>9V</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>1100</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop> </ns0:TS834_2700_Loop> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>5</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>RATING AREA</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>9X</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>A1</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop> </ns0:TS834_2700_Loop> - <ns0:TS834_2700_Loop> - <ns0:LX_MemberReportingCategories> <LX01_AssignedNumber>6</LX01_AssignedNumber> </ns0:LX_MemberReportingCategories> - <ns0:TS834_2750_Loop> - <ns0:N1_ReportingCategory> <N101_EntityIdentifierCode>75</N101_EntityIdentifierCode> <N102_MemberReportingCategoryName>ADDL MAINT REASON</N102_MemberReportingCategoryName> </ns0:N1_ReportingCategory> - <ns0:REF_ReportingCategoryReference> <REF01_ReferenceIdentificationQualifier>17</REF01_ReferenceIdentificationQualifier> <REF02_MemberReportingCategoryReferenceID>CONFIRM</REF02_MemberReportingCategoryReferenceID> </ns0:REF_ReportingCategoryReference> - <ns0:DTP_ReportingCategoryDate> <DTP01_DateTimeQualifier>007</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_MemberReportingCategoryEffectiveDate_s_>20140101</DTP03_MemberReportingCategoryEffectiveDate_s_> </ns0:DTP_ReportingCategoryDate> </ns0:TS834_2750_Loop> </ns0:TS834_2700_Loop> - <ns0:LE_AdditionalReportingCategoriesTermination> <LE01_LoopIdentifierCode>2700</LE01_LoopIdentifierCode> </ns0:LE_AdditionalReportingCategoriesTermination> </ns0:TS834_LS_Loop> </ns0:TS834_2000_Loop> - <ns0:TS834_2000_Loop> - <ns0:INS_MemberLevelDetail> <INS01_MemberIndicator>N</INS01_MemberIndicator> <INS02_IndividualRelationshipCode>01</INS02_IndividualRelationshipCode> <INS03_MaintenanceTypeCode>021</INS03_MaintenanceTypeCode> <INS04_MaintenanceReasonCode>EC</INS04_MaintenanceReasonCode> <INS05_BenefitStatusCode>A</INS05_BenefitStatusCode> </ns0:INS_MemberLevelDetail> - <ns0:REF_SubLoop> - <ns0:REF_SubscriberIdentifier> <REF01_ReferenceIdentificationQualifier>0F</REF01_ReferenceIdentificationQualifier> <REF02_SubscriberIdentifier>PER12341</REF02_SubscriberIdentifier> </ns0:REF_SubscriberIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>17</REF01_ReferenceIdentificationQualifier>

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<REF02_MemberSupplementalIdentifier>999999991</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>6O</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>1000000016</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>23</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00124</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>ZZ</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00123</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> </ns0:REF_SubLoop> - <ns0:DTP_MemberLevelDates> <DTP01_DateTimeQualifier>356</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_StatusInformationEffectiveDate>20140101</DTP03_StatusInformationEffectiveDate> </ns0:DTP_MemberLevelDates> - <ns0:NM1_SubLoop> - <ns0:TS834_2100A_Loop> - <ns0:NM1_MemberName> <NM101_EntityIdentifierCode>IL</NM101_EntityIdentifierCode> <NM102_EntityTypeQualifier>1</NM102_EntityTypeQualifier> <NM103_MemberLastName>Smith</NM103_MemberLastName> <NM104_MemberFirstName>Kathy</NM104_MemberFirstName> <NM108_IdentificationCodeQualifier>34</NM108_IdentificationCodeQualifier> <NM109_MemberIdentifier>273225555</NM109_MemberIdentifier> </ns0:NM1_MemberName> - <ns0:N3_MemberResidenceStreetAddress> <N301_MemberAddressLine>261 Versailles Rd</N301_MemberAddressLine> </ns0:N3_MemberResidenceStreetAddress> - <ns0:N4_MemberCity_State_ZIPCode> <N401_MemberCityName>Frankfort</N401_MemberCityName> <N402_MemberStateCode>KY</N402_MemberStateCode> <N403_MemberPostalZoneorZipCode>40601</N403_MemberPostalZoneorZipCode> <N404_CountryCode>US</N404_CountryCode> <N405_LocationQualifier>CY</N405_LocationQualifier> <N406_LocationIdentifier>Fayette</N406_LocationIdentifier> </ns0:N4_MemberCity_State_ZIPCode> - <ns0:DMG_MemberDemographics> <DMG01_DateTimePeriodFormatQualifier>D8</DMG01_DateTimePeriodFormatQualifier> <DMG02_MemberBirthDate>19710501</DMG02_MemberBirthDate> <DMG03_GenderCode>F</DMG03_GenderCode> <DMG04_MaritalStatusCode>M</DMG04_MaritalStatusCode> - <ns0:C056_CompositeRaceorEthnicityInformation> <C05601_RaceorEthnicityCode>H</C05601_RaceorEthnicityCode> </ns0:C056_CompositeRaceorEthnicityInformation> <DMG06_CitizenshipStatusCode>1</DMG06_CitizenshipStatusCode> </ns0:DMG_MemberDemographics> - <ns0:HLH_MemberHealthInformation> <HLH01_HealthRelatedCode>N</HLH01_HealthRelatedCode> </ns0:HLH_MemberHealthInformation> - <ns0:LUI_MemberLanguage> <LUI01_IdentificationCodeQualifier>LD</LUI01_IdentificationCodeQualifier> <LUI02_LanguageCode>ENG</LUI02_LanguageCode> <LUI04_LanguageUseIndicator>6</LUI04_LanguageUseIndicator> </ns0:LUI_MemberLanguage> </ns0:TS834_2100A_Loop> </ns0:NM1_SubLoop> - <ns0:TS834_2300_Loop> - <ns0:HD_HealthCoverage> <HD01_MaintenanceTypeCode>021</HD01_MaintenanceTypeCode> <HD03_InsuranceLineCode>HLT</HD03_InsuranceLineCode> <HD04_PlanCoverageDescription>Health Care Plus</HD04_PlanCoverageDescription> </ns0:HD_HealthCoverage> - <ns0:DTP_HealthCoverageDates> <DTP01_DateTimeQualifier>348</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_CoveragePeriod>20140101</DTP03_CoveragePeriod> </ns0:DTP_HealthCoverageDates> - <ns0:REF_SubLoop_2> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>CE</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>PLN34567</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>X9</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>ISRPLAN005</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber>

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- <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>1L</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>KHBE-I</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> </ns0:REF_SubLoop_2> </ns0:TS834_2300_Loop> </ns0:TS834_2000_Loop> - <ns0:TS834_2000_Loop> - <ns0:INS_MemberLevelDetail> <INS01_MemberIndicator>N</INS01_MemberIndicator> <INS02_IndividualRelationshipCode>19</INS02_IndividualRelationshipCode> <INS03_MaintenanceTypeCode>021</INS03_MaintenanceTypeCode> <INS04_MaintenanceReasonCode>EC</INS04_MaintenanceReasonCode> <INS05_BenefitStatusCode>A</INS05_BenefitStatusCode> </ns0:INS_MemberLevelDetail> - <ns0:REF_SubLoop> - <ns0:REF_SubscriberIdentifier> <REF01_ReferenceIdentificationQualifier>0F</REF01_ReferenceIdentificationQualifier> <REF02_SubscriberIdentifier>PER12341</REF02_SubscriberIdentifier> </ns0:REF_SubscriberIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>17</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>999999992</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>6O</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>1000000014</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>23</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00125</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> - <ns0:REF_MemberSupplementalIdentifier> <REF01_ReferenceIdentificationQualifier>ZZ</REF01_ReferenceIdentificationQualifier> <REF02_MemberSupplementalIdentifier>ISR00123</REF02_MemberSupplementalIdentifier> </ns0:REF_MemberSupplementalIdentifier> </ns0:REF_SubLoop> - <ns0:DTP_MemberLevelDates> <DTP01_DateTimeQualifier>356</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_StatusInformationEffectiveDate>20140101</DTP03_StatusInformationEffectiveDate> </ns0:DTP_MemberLevelDates> - <ns0:NM1_SubLoop> - <ns0:TS834_2100A_Loop> - <ns0:NM1_MemberName> <NM101_EntityIdentifierCode>IL</NM101_EntityIdentifierCode> <NM102_EntityTypeQualifier>1</NM102_EntityTypeQualifier> <NM103_MemberLastName>Smith</NM103_MemberLastName> <NM104_MemberFirstName>Kathy</NM104_MemberFirstName> <NM108_IdentificationCodeQualifier>34</NM108_IdentificationCodeQualifier> <NM109_MemberIdentifier>273225555</NM109_MemberIdentifier> </ns0:NM1_MemberName> - <ns0:N3_MemberResidenceStreetAddress> <N301_MemberAddressLine>261 Versailles Rd</N301_MemberAddressLine> </ns0:N3_MemberResidenceStreetAddress> - <ns0:N4_MemberCity_State_ZIPCode> <N401_MemberCityName>Frankfort</N401_MemberCityName> <N402_MemberStateCode>KY</N402_MemberStateCode> <N403_MemberPostalZoneorZipCode>40601</N403_MemberPostalZoneorZipCode> <N404_CountryCode>US</N404_CountryCode> <N405_LocationQualifier>CY</N405_LocationQualifier> <N406_LocationIdentifier>Fayette</N406_LocationIdentifier> </ns0:N4_MemberCity_State_ZIPCode> - <ns0:DMG_MemberDemographics> <DMG01_DateTimePeriodFormatQualifier>D8</DMG01_DateTimePeriodFormatQualifier> <DMG02_MemberBirthDate>19710501</DMG02_MemberBirthDate> <DMG03_GenderCode>M</DMG03_GenderCode> <DMG04_MaritalStatusCode>U</DMG04_MaritalStatusCode> - <ns0:C056_CompositeRaceorEthnicityInformation> <C05601_RaceorEthnicityCode>H</C05601_RaceorEthnicityCode> </ns0:C056_CompositeRaceorEthnicityInformation> <DMG06_CitizenshipStatusCode>1</DMG06_CitizenshipStatusCode> </ns0:DMG_MemberDemographics> - <ns0:HLH_MemberHealthInformation> <HLH01_HealthRelatedCode>N</HLH01_HealthRelatedCode> </ns0:HLH_MemberHealthInformation> - <ns0:LUI_MemberLanguage> <LUI01_IdentificationCodeQualifier>LD</LUI01_IdentificationCodeQualifier> <LUI02_LanguageCode>ENG</LUI02_LanguageCode> <LUI04_LanguageUseIndicator>6</LUI04_LanguageUseIndicator> </ns0:LUI_MemberLanguage>

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</ns0:TS834_2100A_Loop> </ns0:NM1_SubLoop> - <ns0:TS834_2300_Loop> - <ns0:HD_HealthCoverage> <HD01_MaintenanceTypeCode>021</HD01_MaintenanceTypeCode> <HD03_InsuranceLineCode>HLT</HD03_InsuranceLineCode> <HD04_PlanCoverageDescription>Health Care Plus</HD04_PlanCoverageDescription> </ns0:HD_HealthCoverage> - <ns0:DTP_HealthCoverageDates> <DTP01_DateTimeQualifier>348</DTP01_DateTimeQualifier> <DTP02_DateTimePeriodFormatQualifier>D8</DTP02_DateTimePeriodFormatQualifier> <DTP03_CoveragePeriod>20140101</DTP03_CoveragePeriod> </ns0:DTP_HealthCoverageDates> - <ns0:REF_SubLoop_2> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>CE</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>PLN34567</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>X9</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>ISRPLAN005</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> - <ns0:REF_HealthCoveragePolicyNumber> <REF01_ReferenceIdentificationQualifier>1L</REF01_ReferenceIdentificationQualifier> <REF02_MemberGrouporPolicyNumber>KHBE-I</REF02_MemberGrouporPolicyNumber> </ns0:REF_HealthCoveragePolicyNumber> </ns0:REF_SubLoop_2> </ns0:TS834_2300_Loop> </ns0:TS834_2000_Loop> - <SE> <SE01_TransactionSegmentCount>94</SE01_TransactionSegmentCount> <SE02_TransactionSetControlNumber>0001</SE02_TransactionSetControlNumber> </SE> </ns0:X12_00501_834>

file:///C:/BizTalk_Locations/EDI834Inbound_WIP/XPath_834Document/%7B0A791A5... 5/6/2013