/// <summary>
/// Build benefit enrollment.
/// Original from http://www.x12.org/examples/005010X220/enroll-employee-in-multiple-health-care-insurance-products/
/// </summary>
static TS834 BuildBenefitEnrollment(string controlNumber)
{
var result = new TS834();
// Used to indicate the start of a transaction set and to specify a transaction set control number.
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "834";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
// This is an original transaction uniquely identified by the sender with reference #12456. The transaction was created on 5/20/1998 at 12:00 Noon.
result.BGN_BeginningSegment = new BGN_BeginningSegment();
result.BGN_BeginningSegment.TransactionSetPurposeCode_01 = "00";
result.BGN_BeginningSegment.TransactionSetReferenceNumber_02 = "12456";
result.BGN_BeginningSegment.TransactionSetCreationDate_03 = "19980520";
result.BGN_BeginningSegment.TransactionSetCreationTime_04 = "1200";
result.BGN_BeginningSegment.ActionCode_08 = "2";
// Occurrence of N1 Loops in any order
result.AllN1 = new All_N1_834();
// Begin 1000A Loop
result.AllN1.Loop1000A = new Loop_1000A_834();
// Specifies the sponsor/sender's tax ID number.
result.AllN1.Loop1000A.N1_SponsorName = new N1_SponsorName();
result.AllN1.Loop1000A.N1_SponsorName.EntityIdentifierCode_01 = "P5";
result.AllN1.Loop1000A.N1_SponsorName.IdentificationCodeQualifier_03 = "FI";
result.AllN1.Loop1000A.N1_SponsorName.IntermediaryBankIdentifier_04 = "999888777";
// End 1000A Loop
// Begin 1000B Loop
result.AllN1.Loop1000B = new Loop_1000B_834();
// Specifies the insurance company/receiver's tax ID number.
result.AllN1.Loop1000B.N1_Payer = new N1_Payer();
result.AllN1.Loop1000B.N1_Payer.EntityIdentifierCode_01 = "IN";
result.AllN1.Loop1000B.N1_Payer.IdentificationCodeQualifier_03 = "FI";
result.AllN1.Loop1000B.N1_Payer.IntermediaryBankIdentifier_04 = "654456654";
// End 1000B Loop
// Repeating 2000 Loops
result.Loop2000 = new List <Loop_2000_834>();
// Begin 2000 Loop
var loop2000 = new Loop_2000_834();
// Beginning of Table 2. Indicates that the subscriber (John Doe) is adding coverage as an active employee.
loop2000.INS_MemberLevelDetail = new INS_MemberLevelDetail();
loop2000.INS_MemberLevelDetail.InsuredIndicator_01 = "Y";
loop2000.INS_MemberLevelDetail.IndividualRelationshipCode_02 = "18";
loop2000.INS_MemberLevelDetail.MaintenanceTypeCode_03 = "021";
loop2000.INS_MemberLevelDetail.MaintenanceReasonCode_04 = "20";
loop2000.INS_MemberLevelDetail.BenefitStatusCode_05 = "A";
loop2000.INS_MemberLevelDetail.EmploymentStatusCode_08 = "FT";
// Occurrence of REF segments in any order
loop2000.AllREF = new All_REF_834_2();
// John's subscriber ID number.
loop2000.AllREF.REF_SubscriberIdentifier = new REF_SubscriberIdentifier();
loop2000.AllREF.REF_SubscriberIdentifier.ReferenceIdentificationQualifier_01 = "0F";
loop2000.AllREF.REF_SubscriberIdentifier.MemberGrouporPolicyNumber_02 = "123456789";
// This is the group number assigned by the carrier.
loop2000.AllREF.REF_MemberPolicyNumber = new REF_MemberPolicyNumber();
loop2000.AllREF.REF_MemberPolicyNumber.ReferenceIdentificationQualifier_01 = "1L";
loop2000.AllREF.REF_MemberPolicyNumber.MemberGrouporPolicyNumber_02 = "123456001";
// Repeating DTP
loop2000.DTP_MemberLevelDates = new List <DTP_MemberLevelDates>();
// The eligibility date for this transaction is 5/23/1996.
var dtp1 = new DTP_MemberLevelDates();
dtp1.DateTimeQualifier_01 = "356";
dtp1.DateTimePeriodFormatQualifier_02 = "D8";
dtp1.AccidentDate_03 = "19960523";
loop2000.DTP_MemberLevelDates.Add(dtp1);
// Occurrence of N1 Loops in any order
loop2000.AllNM1 = new All_NM1_834();
// Begin 2100A Loop
loop2000.AllNM1.Loop2100A = new Loop_2100A_834();
// Subscriber's name.
loop2000.AllNM1.Loop2100A.NM1_MemberName = new NM1_MemberName();
loop2000.AllNM1.Loop2100A.NM1_MemberName.EntityIdentifierCode_01 = "IL";
loop2000.AllNM1.Loop2100A.NM1_MemberName.EntityTypeQualifier_02 = "1";
loop2000.AllNM1.Loop2100A.NM1_MemberName.ResponseContactLastorOrganizationName_03 = "DOE";
loop2000.AllNM1.Loop2100A.NM1_MemberName.ResponseContactFirstName_04 = "JOHN";
loop2000.AllNM1.Loop2100A.NM1_MemberName.ResponseContactMiddleName_05 = "P";
loop2000.AllNM1.Loop2100A.NM1_MemberName.IdentificationCodeQualifier_08 = "34";
loop2000.AllNM1.Loop2100A.NM1_MemberName.ResponseContactIdentifier_09 = "123456789";
// John's home phone number is (717)234-3334 and his work number is (717) 234-1240.
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers = new PER_MemberCommunicationsNumbers();
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers.ContactFunctionCode_01 = "IP";
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers.CommunicationNumberQualifier_03 = "HP";
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers.ResponseContactCommunicationNumber_04 = "7172343334";
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers.CommunicationNumberQualifier_05 = "WP";
loop2000.AllNM1.Loop2100A.PER_MemberCommunicationsNumbers.ResponseContactCommunicationNumber_06 = "7172341240";
// This is John's street address.
loop2000.AllNM1.Loop2100A.N3_MemberResidenceStreetAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000.AllNM1.Loop2100A.N3_MemberResidenceStreetAddress.ResponseContactAddressLine_01 = "100 MARKET ST";
loop2000.AllNM1.Loop2100A.N3_MemberResidenceStreetAddress.ResponseContactAddressLine_02 = "APT 3G";
// This is John's city, state zip code and county.
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CAMP HILL";
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA";
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17011";
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode.LocationQualifier_05 = "CY";
loop2000.AllNM1.Loop2100A.N4_MemberCity_State_ZIPCode.LocationIdentifier_06 = "CUMBERLAND";
// This is John's date of birth and gender.
loop2000.AllNM1.Loop2100A.DMG_MemberDemographics = new DMG_DependentDemographicInformation();
loop2000.AllNM1.Loop2100A.DMG_MemberDemographics.DateTimePeriodFormatQualifier_01 = "D8";
loop2000.AllNM1.Loop2100A.DMG_MemberDemographics.DependentBirthDate_02 = "19400816";
loop2000.AllNM1.Loop2100A.DMG_MemberDemographics.DependentGenderCode_03 = "M";
// End 2100A Loop
// Repeating 2300 Loops
loop2000.Loop2300 = new List <Loop_2300_834>();
// Begin 2300 Loop 1
var loop23001 = new Loop_2300_834();
// John is enrolling in a health benefit.
loop23001.HD_HealthCoverage = new HD_HealthCoverage();
loop23001.HD_HealthCoverage.MaintenanceTypeCode_01 = "021";
loop23001.HD_HealthCoverage.InsuranceLineCode_03 = "HLT";
// Repeating DTP
loop23001.DTP_HealthCoverageDates = new List <DTP_HealthCoverageDates>();
// The benefits under this plan begin 6/01/1996.
var dtp2 = new DTP_HealthCoverageDates();
dtp2.DateTimeQualifier_01 = "348";
dtp2.DateTimePeriodFormatQualifier_02 = "D8";
dtp2.AccidentDate_03 = "19960601";
loop23001.DTP_HealthCoverageDates.Add(dtp2);
// Repeating 2320 Loops
loop23001.Loop2320 = new List <Loop_2320_834>();
// Begin 2320 Loop
var loop23201 = new Loop_2320_834();
// This lets the carrier know that John has COB with another company.
loop23201.COB_CoordinationofBenefits = new COB_CoordinationofBenefits();
loop23201.COB_CoordinationofBenefits.PayerResponsibilitySequenceNumberCode_01 = "P";
loop23201.COB_CoordinationofBenefits.MemberGrouporPolicyNumber_02 = "890111";
loop23201.COB_CoordinationofBenefits.CoordinationofBenefitsCode_03 = "5";
// End 2320 Loop
loop23001.Loop2320.Add(loop23201);
// End 2300 Loop 1
loop2000.Loop2300.Add(loop23001);
// Begin 2300 Loop 2
var loop23002 = new Loop_2300_834();
// John is enrolling in the Dental benefit.
loop23002.HD_HealthCoverage = new HD_HealthCoverage();
loop23002.HD_HealthCoverage.MaintenanceTypeCode_01 = "021";
loop23002.HD_HealthCoverage.InsuranceLineCode_03 = "DEN";
// Repeating DTP
loop23002.DTP_HealthCoverageDates = new List <DTP_HealthCoverageDates>();
// The benefits under this plan begin 6/01/1996.
var dtp3 = new DTP_HealthCoverageDates();
dtp3.DateTimeQualifier_01 = "348";
dtp3.DateTimePeriodFormatQualifier_02 = "D8";
dtp3.AccidentDate_03 = "19960601";
loop23002.DTP_HealthCoverageDates.Add(dtp3);
// End 2300 Loop 2
loop2000.Loop2300.Add(loop23002);
// Begin 2300 Loop 3
var loop23003 = new Loop_2300_834();
// John is enrolling in the Vision benefit.
loop23003.HD_HealthCoverage = new HD_HealthCoverage();
loop23003.HD_HealthCoverage.MaintenanceTypeCode_01 = "021";
loop23003.HD_HealthCoverage.InsuranceLineCode_03 = "VIS";
// Repeating DTP
loop23003.DTP_HealthCoverageDates = new List <DTP_HealthCoverageDates>();
// The benefits under this plan begin 6/01/1996.
var dtp4 = new DTP_HealthCoverageDates();
dtp4.DateTimeQualifier_01 = "348";
dtp4.DateTimePeriodFormatQualifier_02 = "D8";
dtp4.AccidentDate_03 = "19960601";
loop23003.DTP_HealthCoverageDates.Add(dtp4);
// End 2300 Loop 3
loop2000.Loop2300.Add(loop23003);
// End 2000 Loop
result.Loop2000.Add(loop2000);
return(result);
}
/// <summary>
/// Sample claim
/// </summary>
static TS834 CreateBenefit(string controlNumber)
{
string CurrentDate = DateTime.Now.ToString("yyyyMMdd");
var result = new TS834();
//Heading
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "834";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X222A1";
result.BGN = new BGN();
result.BGN.TransactionSetPurposeCode_01 = "00";
result.BGN.TransactionSetReferenceNumber_02 = "WSU-WEY-20050221-1";
result.BGN.TransactionSetCreationDate_03 = CurrentDate;
result.BGN.TransactionSetCreationTime_04 = DateTime.Now.ToString("hhmmss");
result.BGN.TimeZoneCode_05 = "PT"; //Optional but most Carriers use
//result.BGN.ReferenceIdentification_06 = ""; //Not usually sent
result.BGN.ActionCode_07 = "4"; //2 = Change, 4 = Verify, RX = replace
//Optional REF
result.REF_TransactionSetPolicyNumber = new REF();
result.REF_TransactionSetPolicyNumber.ReferenceIdentificationQualifier_01 = "38";
result.REF_TransactionSetPolicyNumber.ReferenceIdentification_02 = "01-23456";//Carrier/Vendor specific
//Optional DTP
result.DTP_FileEffectiveDate.DateTimeQualifier_01 = "007";
result.DTP_FileEffectiveDate.DateTimePeriodFormatQualifier_02 = "D8";
result.DTP_FileEffectiveDate.DateTimePeriod_03 = CurrentDate;
//Optional QTY
result.QTY_TransactionSetControlTotals = new QTY();
result.QTY_TransactionSetControlTotals.QuantityQualifier_01 = "TO";
result.QTY_TransactionSetControlTotals.Quantity_02 = "1";//Only one record for this example.
//Loop 1000
result.All_NM1 = new All_NM1();
//Loop 1000A
result.All_NM1.Loop_1000A = new Loop_1000A();
result.All_NM1.Loop_1000A.NM1_SponsorName.EntityIdentifierCode_01 = "P5";
result.All_NM1.Loop_1000A.NM1_SponsorName.Name_02 = "Sponsor Name";
result.All_NM1.Loop_1000A.NM1_SponsorName.IdentificationCodeQualifier_03 = "FI";
result.All_NM1.Loop_1000A.NM1_SponsorName.IdentificationCode_04 = "1223456";
//Loop 1000B
result.All_NM1.Loop_1000B = new Loop_1000B();
result.All_NM1.Loop_1000B.NM1_PayerName.EntityIdentifierCode_01 = "IN";
result.All_NM1.Loop_1000B.NM1_PayerName.Name_02 = "ABC PAYER";
result.All_NM1.Loop_1000B.NM1_PayerName.IdentificationCodeQualifier_03 = "FI";
result.All_NM1.Loop_1000B.NM1_PayerName.IdentificationCode_04 = "11-111111";
//result.All_NM1.Loop_1000C = new Loop_1000C();
//Usually brokers are optional fields
//Loop 2000
//INS
result.Loop_2000 = new List <Loop_2000>();
Loop_2000 Loop_2000 = new Loop_2000();
Loop_2000.INS = new INS();
Loop_2000.INS.YesNoConditionorResponseCode_01 = "Y";//Subscriber/Member record
Loop_2000.INS.IndividualRelationshipCode_02 = "18";
Loop_2000.INS.MaintenanceTypeCode_03 = "021";
Loop_2000.INS.MaintenanceReasonCode_04 = "20";
Loop_2000.INS.BenefitStatusCode_05 = "A";
Loop_2000.INS.MedicarePlanCode_06 = "E";
//Loop_2000.INS.ConsolidatedOmnibusBudgetReconciliationActCOBRAQualifyingEventCode_07 = "0";
Loop_2000.INS.EmploymentStatusCode_08 = "AC";
//Loop_2000.INS.StudentStatusCode_09 = "N";
Loop_2000.INS.YesNoConditionorResponseCode_10 = "N";
//Loop_2000.INS.DateTimePeriodFormatQualifier_11 = "";//Dealth Date: Carrier specific
//Loop_2000.INS.DateTimePeriod_12 = "";
Loop_2000.INS.ConfidentialityCode_13 = "";//Usually left blank.
//Loop_2000.INS.CityName_14 = "City"; //14-17 usually not sent in favor of N3/N4 segments
Loop_2000.Ref_SubscriberIdentifier = new REF();
Loop_2000.Ref_SubscriberIdentifier.ReferenceIdentificationQualifier_01 = "0F";
Loop_2000.Ref_SubscriberIdentifier.ReferenceIdentification_02 = "12345678";//typically a UUID or SSN
Loop_2000.Ref_MemberSupplementalIdentifier = new REF();
Loop_2000.Ref_MemberSupplementalIdentifier.ReferenceIdentificationQualifier_01 = "1L";
Loop_2000.Ref_MemberSupplementalIdentifier.ReferenceIdentification_02 = "ABC123";//Group or Policy Number usually Carrier specific
DTP DTP_MemberHireSegment = new DTP();
DTP_MemberHireSegment.DateTimeQualifier_01 = "336";
DTP_MemberHireSegment.DateTimePeriodFormatQualifier_02 = "D8";
DTP_MemberHireSegment.DateTimePeriod_03 = "20170501";
DTP DTP_MemberEffectiveSegment = new DTP();
DTP_MemberEffectiveSegment.DateTimeQualifier_01 = "356";
DTP_MemberEffectiveSegment.DateTimePeriodFormatQualifier_02 = "D8";
DTP_MemberEffectiveSegment.DateTimePeriod_03 = "20170601";
//Example term of coverage
//DTP DTP_MemberEligibilityEndSegment = new DTP();
//DTP_MemberEligibilityEndSegment.DateTimeQualifier_01 = "357";
//DTP_MemberEligibilityEndSegment.DateTimePeriodFormatQualifier_02 = "D8";
//DTP_MemberEligibilityEndSegment.DateTimePeriod_03 = "20171231";
Loop_2000.DTP_MemberLevelDates.Add(DTP_MemberHireSegment);
Loop_2000.DTP_MemberLevelDates.Add(DTP_MemberEffectiveSegment);
result.Loop_2000.Add(Loop_2000);
result.Loop_2100A = new List <Loop_2100A>();
Loop_2100A Loop_2100A = new Loop_2100A();
Loop_2100A.NM1_MemberName = new NM1();
Loop_2100A.NM1_MemberName.EntityIdentifierCode_01 = "IL";
Loop_2100A.NM1_MemberName.Name_02 = "1";
Loop_2100A.NM1_MemberName.IdentificationCodeQualifier_03 = "MemberLastName";
Loop_2100A.NM1_MemberName.IdentificationCode_04 = "MemberFirstname";
//Optional Loop 2100A Segment NM1 05-09
Loop_2100A.Per_MemberCommunicationNumbers = new PER();
Loop_2100A.Per_MemberCommunicationNumbers.ContactFunctionCode_01 = "IP";
//Loop_2100A.Per_MemberCommunicationNumbers.Name_02 = "abc123";
Loop_2100A.Per_MemberCommunicationNumbers.CommunicationNumberQualifier_03 = "CP";
Loop_2100A.Per_MemberCommunicationNumbers.CommunicationNumber_04 = "9991111111";
//Optional Loop 2100A Segment Per
Loop_2100A.N3_MemberResidenceStreetAddress = new N3_MemberResidenceStreetAddress();
Loop_2100A.N3_MemberResidenceStreetAddress.Address_Information_01 = "444 Fake street";
Loop_2100A.N3_MemberResidenceStreetAddress.Address_Information_02 = "Apt 300";
Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode = new N4_OtherSubscriberCity_State_ZIPCode();
Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.OtherSubscriberCityName_01 = "TestCity";
Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.OtherSubscriberStateorProvinceCode_02 = "CA";
Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.OtherSubscriberPostalZoneorZIPCode_03 = "93710";
//Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.CountryCode_04 = "US";//Optional. Only outside the US.
//Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.LocationQualifier_05 = "";//Optional. 60 = Area and CY = Country/Parish
//Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.LocationIdentifier_06 = "";//Optional. Carrier/Plan specific.
//Loop_2100A.N4_OtherSubscriberCity_State_ZIPCode.CountrySubdivisionCode_07 = "";//Optional. Use country subdivision codes ISO 3166.
Loop_2100A.DMG_MemberDemographicInformation = new DMG_MemberDemographicInformation();
Loop_2100A.DMG_MemberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
Loop_2100A.DMG_MemberDemographicInformation.SubscriberBirthDate_02 = "19330706";
Loop_2100A.DMG_MemberDemographicInformation.SubscriberGenderCode_03 = "M";
//Optional Loop 2100A Segment DMG 04-11
//Optional sgment unless Carrier/Client specifically ask for it.
Loop_2100A.EC_EmploymentClass = new EC_EmploymentClass();
Loop_2100A.EC_EmploymentClass.EmpoymentClassCode_01 = "01";
Loop_2100A.EC_EmploymentClass.EmpoymentClassCode_02 = "03";
Loop_2100A.EC_EmploymentClass.EmpoymentClassCode_03 = "11";
//Optional Member Income segment
//Used for Carriers/Employeers that need specific member income amounts as part of billable plans.
Loop_2100A.ICM_MemberIncome.FrequencyCode_01 = "1";//Typically weekly or monthly
Loop_2100A.ICM_MemberIncome.MonetaryAmount_02 = "2000";
Loop_2100A.ICM_MemberIncome.Quantity_03 = "40";
Loop_2100A.ICM_MemberIncome.LocationIdentifier_04 = "93710"; //Most will default to a an internal location code or Zip
Loop_2100A.ICM_MemberIncome.SalaryGrade_05 = "A"; //Abitrary Code set by the employeer
//TODO: Optional Segments
//AMT Member Policy Amounts
//HLH Member Health Information
//LUI Member Language
//NM1 Member mailing Address
//N3 Member Mail Street Address
//N4 Member Mail city, State, Zip
result.Loop_2100A.Add(Loop_2100A);
//Loop 2200:
//DSB Disability Info
//DTP Disability Eligibility Dates
//Loop 2300 (Required on most Carriers)
result.Loop_2300 = new List <Loop_2300>();
Loop_2300 Loop_2300 = new Loop_2300();
Loop_2300.HD_HealthCoverage = new HD();
Loop_2300.HD_HealthCoverage.MaintenanceTypeCode_01 = "026";
//Loop_2300.HD_HealthCoverage.MaintenanceReasonCode_02 = "1";//usually Carrier specific
Loop_2300.HD_HealthCoverage.InsuranceLineCode_03 = "PPO";
Loop_2300.HD_HealthCoverage.PlanCoverageDescription_04 = "Test PPO Plan"; //Optional. Some carriers make this a required field with specific reporting values.
Loop_2300.HD_HealthCoverage.CoverageLevelCode_05 = "EMP"; //Employee only is usually EMP or IND Carrier specific
//06-07 almost never used
Loop_2300.HD_HealthCoverage.UnderwritingDecisionCode_08 = "Y"; //Y/N value but can be removed if nessessary
Loop_2300.HD_HealthCoverage.YesNoConditionorResponseCode_09 = "N"; //Sometimes used as a Late Enrollment Indicator
DTP DTP_MaintenanceEffective = new DTP();
DTP_MaintenanceEffective.DateTimeQualifier_01 = "303";
DTP_MaintenanceEffective.DateTimePeriodFormatQualifier_02 = "D3";
DTP_MaintenanceEffective.DateTimePeriod_03 = "20151001";
Loop_2300.DTP_HealthCoverageDates.Add(DTP_MaintenanceEffective);
DTP DTP_BenefitBegin = new DTP();
DTP_BenefitBegin.DateTimeQualifier_01 = "348";
DTP_BenefitBegin.DateTimePeriodFormatQualifier_02 = "348";
DTP_BenefitBegin.DateTimePeriod_03 = "20150901";
Loop_2300.DTP_HealthCoverageDates.Add(DTP_BenefitBegin);
REF REF_ClientReportingCategory = new REF();
REF_ClientReportingCategory.ReferenceIdentificationQualifier_01 = "17";
REF_ClientReportingCategory.ReferenceIdentification_02 = "12345";
Loop_2300.REF_HealthCoveragePolicyNumbers.Add(REF_ClientReportingCategory);
REF REF_GroupPolicyNumber = new REF();
REF_GroupPolicyNumber.ReferenceIdentificationQualifier_01 = "1L";
REF_GroupPolicyNumber.ReferenceIdentification_02 = "54321";
Loop_2300.REF_HealthCoveragePolicyNumbers.Add(REF_GroupPolicyNumber);
result.Loop_2300.Add(Loop_2300);
result.Loop_2310 = new List <Loop_2310>();
Loop_2310 Loop_2310 = new Loop_2310();
Loop_2310.LX_ProviderInformation = new LX();
Loop_2310.LX_ProviderInformation.AssignedNumber_01 = "1";
Loop_2310.NM1_ReferingProviderName = new NM1_ReferringProviderName();
Loop_2310.NM1_ReferingProviderName.EntityIdentifierCode_01 = "OD";
Loop_2310.NM1_ReferingProviderName.EntityTypeQualifier_02 = "1";
Loop_2310.NM1_ReferingProviderName.ReferringProviderLastName_03 = "ABC Hospital";
Loop_2310.NM1_ReferingProviderName.ReferringProviderFirstName_04 = "Care";
Loop_2310.NM1_ReferingProviderName.ReferringProviderMiddleNameorInitial_05 = "A";
Loop_2310.NM1_ReferingProviderName.NamePrefix_06 = "Sr";
Loop_2310.NM1_ReferingProviderName.ReferringProviderNameSuffix_07 = "";
Loop_2310.NM1_ReferingProviderName.IdentificationCodeQualifier_08 = "SV";
Loop_2310.NM1_ReferingProviderName.ReferringProviderIdentifier_09 = "Doc PPO";
Loop_2310.NM1_ReferingProviderName.EntityRelationshipCode_10 = "25";
result.Loop_2310.Add(Loop_2310);
result.Loop_2320 = new List <Loop_2320>();
Loop_2320 Loop_2320 = new Loop_2320();
Loop_2320.COB_CoordinationOfBenefits.PayerResponsibilitySequenceNumberCode_01 = "P";
Loop_2320.COB_CoordinationOfBenefits.ReferenceIdentification_02 = "A";
Loop_2320.COB_CoordinationOfBenefits.CoordinationofBenefitsCode_03 = "1";
Loop_2320.COB_CoordinationOfBenefits.ServiceTypeCode_04 = "1";
Loop_2320.REF_AdditionalCoordinationOfBenefitsIdentifiers = new List <REF>();
REF REFAccountCode = new REF();
REFAccountCode.ReferenceIdentificationQualifier_01 = "60";
REFAccountCode.ReferenceIdentification_02 = "12345";
Loop_2320.REF_AdditionalCoordinationOfBenefitsIdentifiers.Add(REFAccountCode);
Loop_2320.DTP_CoordinationOfBenefitsEleigibilityDates = new List <DTP>();
DTP DTP_CoordinationOfBenefitBegin = new DTP();
DTP_CoordinationOfBenefitBegin.DateTimeQualifier_01 = "334";
DTP_CoordinationOfBenefitBegin.DateTimePeriodFormatQualifier_02 = "D8";
DTP_CoordinationOfBenefitBegin.DateTimePeriod_03 = "20150101";
result.Loop_2320.Add(Loop_2320);
Loop_2330 Loop_2330 = new Loop_2330();
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity = new NM1_InsuranceProviderName();
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.EntityIdentifierCode_01 = "IN";
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.EntityTypeQualifier_02 = "2";
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.ReferringProviderLastName_03 = "Insurance";
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.ReferringProviderFirstName_04 = "ABC";
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.IdentificationCodeQualifier_08 = "FI";
Loop_2330.NM1_CoordinationOfBenefitsRelatedEntity.ReferringProviderIdentifier_09 = "12-345678";
//Misleading as "Loop" only contains NM1 element once.
result.Loop_2330 = Loop_2330;
//Optional Report Category
//Misleading as "Loop" usually contains LX element only once.
Loop_2700 Loop_2700 = new Loop_2700();
Loop_2700.LX_MemberReportingCategories = new LX();
Loop_2700.LX_MemberReportingCategories.AssignedNumber_01 = "2";
return(result);
}
