EDI 834 Benefit Enrollment and Maintenance Specifications
The EDI 834 transaction set represents a Benefit Enrollment and Maintenance document. It is used by employers, as well as unions, government agencies or insurance agencies, to enroll members in a healthcare benefit plan. The EDI 834 has been specified by HIPAA 5010 standards for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information. The 834 transaction may be used for any of the following functions relative to health plans:
- New enrollments
- Changes in a member’s enrollment
- Reinstatement of a member’s benefit enrollment
- Disenrollment of members (i.e., termination of plan membership)
- Subscriber name and identification
- Plan network identification
- Subscriber eligibility and/or benefit information
- Product/service identification
EDI 834 Format
ISA*01*0000000000*01*0000000000*ZZ*ABCDEFGHIJKLMNO*ZZ*123456789012345*101127*1719*U*00400*000003438*0*P*>
GS*PO*4405197800*999999999*20101127*1719*1421*X*004010VICS
ST*834*0179
BGN*00*1*20050315*110650****4
REF*38*SAMPLE_POLICY_NUMBER
DTP*303*D8*20080321
N1*P5*COMPAN_NAME*FI*000000000
INS*Y*18*030*20*A
REF*0F*SUBSCRIBER_NUMBER
NM1*IL*1*JOHN DOE*R***34*1*0000000
PER*IP**HP*2138051111
N3*123 SAMPLE RD
N4*CITY*ST*12345
DMG*D8*19690101 *F
HD*030
DTP*348*D8*20080101
REF*1L*INDIV_POLICY_NO
SE*16*0179
GE*1*1421
IEA*1*000003438
EDI 834 Specification
This X12 Transaction Set contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA). For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups. For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.
Sources
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., Falls Church, VA. http://www.x12.org