Example 01: Initial Add Single Member

Reporting the initial sending of this member's information to the information receiver.

The Submitter (Submitter Name) with ETIN S12345 is submitting this transaction to the Receiver (Receiver Name) with ETIN R12345. The source of the information in this transaction is Infosrc Name with a ETIN of IS12345.

The member being sent in this transaction is William Smith. He has a member ID of 920399398 and his Social Security Number (SSN) is 202443070. He is also the subscriber. William was born on September 14, 1970, is single, and is a white male. His employment class is Non-Union. He has no health related codes to report. William speaks English as his native language.

William lives at 1715 Southwind Ave, Anytown, PA 17111-000, but his mailing address is 2324 Northwind Ave., Anytown, PA 17111-0000. His employer is Member Employer Name. The responsible person for William is Person Responsible.

William has Employee Only HMO coverage. This coverage has a maintenance effective date of August 1, 2019 which is also when the benefit begins. This coverage has a deductible amount of $250 and a premium amount of $100. The group number is 888888.

William’s primary care physician is PCP Jones who has a NPI of 1700813623. PCP Jones is a General Practice physician

William has coverage under 2 different insurers. His primary insurer is Infosrcname, who is also the Information Source for this transaction. His secondary insurer is Secondary Ins Co.

William also has Employee Only Dental coverage. This coverage has a maintenance effective date of August 1, 2019 which is also when the benefit begins. This coverage has a deductible amount of $50 and a premium amount of $10. The group number is 333333.

William’s dentist is Dentist Jones who has a NPI of 1700814449. Dentist Jones is a General Practice dentist.