Specifications for EDI 834, Benefit Enrollment and Maintenance

An enrollment and maintenance document for benefits is represented by the EDI 834 transaction set. It is used to enrol members in a healthcare benefit plan by corporations, unions, governmental organisations, or insurance companies. For the electronic transmission of member enrollment data, including information on benefits, plan subscriptions, and employee demographics, HIPAA 5010 guidelines have established the EDI 834. In relation to health insurance, the 834 transaction may be used for any of the following purposes:

• New enrollments
• A member's enrolment status changing
• enrolment in benefits for a member to be restored
• Disenrollment of participants (i.e., cancellation of plan enrollment)

Employers often provide the information to healthcare payer organisations, who are in charge of paying medical claims and managing insurance and/or benefits. Insurance businesses, healthcare professional associations like HMOs or PPOs, and governmental organisations like Medicare and Medicaid may fall under this category. Typical 834 documents might contain the following details:

• Name and identity of the subscriber
• Network identification in a plan
• Information about subscriber eligibility and/or benefits Identification of the product or service

An 834 transaction requires the sender to react with a 999 Implementation Acknowledgement, which acknowledges receipt of the file and expresses approval or disapproval of the document. For healthcare facilities obliged to adhere to HIPAA 5010 requirements,

Format of EDI 834

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

Specification of EDI 834

For usage in the context of an Electronic Data Interchange (EDI) system, this X12 Transaction Set defines the format and data contents for the Benefit Enrollment and Maintenance Transaction Set (834) set. The sponsor of the insurance product and the payer may communicate with one another using this transaction set. A third party administrator (TPA) may or may not be used in such transaction(s). The party or organisation that ultimately bears the cost of the coverage, benefit, or product is referred to as the sponsor for the purposes of this standard. Employers, unions, governmental organisations, associations, and insurance companies can all serve as sponsors. An organisation that manages the insurance benefit or product, pays claims, or does both is referred to as the payer. A payer may be an insurance provider, HMO, PPO, government agency (such as Medicare, Medicaid, Champus, etc.), or an organisation that has a contract with one of the aforementioned organisations. If a sponsor chooses not to carry out this job themselves, the sponsor may contract with a third party administrator (TPA) to manage data collection from individuals covered by the sponsor for the purposes of the 834 transaction set.