HIPAA 5010 rules for the electronic transmission of member enrollment information, including benefits, plan subscriptions, and employee demographic data, have established the EDI 834 transaction set and format. The following health plan-related operations may make use of the EDI 834 transaction set: new member enrollments, member enrollment adjustments, member enrollment reinstatements, and member disenrollments (i.e., termination of plan participation).
It is possible to create communication between the payer and the insurance product sponsor using the EDI 834 A1. The sponsor is the person or organisation who ultimately bears the cost of the product, service, or coverage. Employers, unions, governmental organisations, associations, and insurance companies can all serve as sponsors. A third party administrator (TPA) may or may not be used in such transaction(s).
An organisation that pays claims, manages the insurance product or benefit, or both is referred to as the payer in EDI 834 A1. The payer might be a government agency (Medicare, Medicaid, etc.), an insurance company, an HMO, a PPO, a preferred provider organisation, or a third party administrator (TPA) or third party organisation (TPO) that has a contract with one of those organisations.
If a sponsor chooses not to fulfil this role, a third party administrator (TPA) might be hired to collect data from people the sponsor covers.
Transmission Explanation
| ST*834*12345*005010X220A1~ |
Used to indicate the start of a transaction set and to specify a transaction set control number. |
| BGN*00*12456*19980520*1200****2~ |
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. |
| N1*P5**FI*999888777~ |
Specifies the sponsor/sender’s tax ID number. |
| N1*IN**FI*654456654~ |
Specifies the insurance company/receiver’s tax ID number. |
| INS*Y*18*021*20*A***FT~ |
Beginning of Table 2. Indicates that the subscriber (John Doe) is adding coverage as an active employee. |
| REF*0F*123456789~ |
John’s subscriber ID number. |
| REF*1L*123456001~ |
This is the group number assigned by the carrier. |
| DTP*356*D8*19960523~ |
The eligibility date for this transaction is 5/23/1996. |
| NM1*IL*1*DOE*JOHN*P***34*123456789~ |
Subscriber’s name. |
| PER*IP**HP*7172343334*WP*7172341240~ |
John’s home phone number is (717)234-3334 and his work number is (717) 234-1240. |
| N3*100 MARKET ST*APT 3G~ |
This is John’s street address. |
| N4*CAMP HILL*PA*17011**CY*CUMBERLAND~ |
This is John’s city, state zip code and county. |
| DMG*D8*19400816*M~ |
This is John’s date of birth and gender. |
| HD*021**HLT~ |
John is enrolling in a health benefit. |
| DTP*348*D8*19960601~ |
The benefits under this plan begin 6/01/1996. |
| COB*P*890111*5~ |
This lets the carrier know that John has COB with another company. |
| HD*021**DEN~ |
John is enrolling in the Dental benefit. |
| DTP*348*D8*19960601~ |
The benefits under this plan begin 6/01/1996. |
| HD*021**VIS~ |
John is enrolling in the Vision benefit. |
| DTP*348*D8*19960601~ |
The benefits under this plan begin 6/01/1996. |
| SE*21*12345~ |
End of transaction set. 21 segments were sent and the control number in the ST segment is 12345. |
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