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EDI 834 X220A1 - Benefit Enrollment and Maintenance

Functional Group BE

X12N Insurance Subcommittee

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.

What is an EDI 834?

An EDI 834 Benefit Enrollment and Maintenance is sent from employers to insurance providers to communicate health insurance details about employees. It contains information about the sponsor and the insurance company (N1 segment), the person to be enrolled (NM1 segment), and eligibility / benefit information (HD segment). It must be HIPAA 00510 compliant.

How is an EDI 834 used?

For example, an Employer A submits an EDI 834 Benefit Enrollment and Maintenance to Insurance Provider B to enroll a new employee into the corporate health care plan.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0200 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 0300 · REF · Transaction Set Policy Number · Max 1 · Optional

   To specify identifying information

   The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.
   Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set.

4. 0400 · DTP · File Effective Date · Max >1 · Optional

   To specify any or all of a date, a time, or a time period

   Required when specified in the contract. If not required by this implementation guide, do not send.

5. 0600 · QTY · Transaction Set Control Totals · Max 3 · Optional

   To specify quantity information

   Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send.

6. 1000A Loop Mandatory Repeat 1

   1. 0700 · N1 · Sponsor Name · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

      This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.

7. 1000B Loop Mandatory Repeat 1

   1. 0700 · N1 · Payer · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

      This loop identifies the payer. See section 1.5 for the definition of payer.

8. 1000C Loop Optional Repeat 2

   1. 0700 · N1 · TPA/Broker Name · Max 1 · Mandatory

      To identify a party by type of organization, name, and code

      Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.

   2. 1100C Loop Optional Repeat 1

      1. 1200 · ACT · TPA/Broker Account Information · Max 1 · Mandatory

         To specify account information

         Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 0100 · INS · Member Level Detail · Max 1 · Mandatory

      To provide benefit information on insured entities

      Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.

   2. 0200 · REF · Subscriber Identifier · Max 1 · Mandatory

      To specify identifying information

      This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
      The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available.

   3. 0200 · REF · Member Policy Number · Max 1 · Optional

      To specify identifying information

      The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.
      Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send.

   4. 0200 · REF · Member Supplemental Identifier · Max 13 · Optional

      To specify identifying information

      Required when sending additional identifying information on the member. If not required by this implementation guide, do not send.

   5. 0250 · DTP · Member Level Dates · Max 24 · Optional

      To specify any or all of a date, a time, or a time period

      Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.
      While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective.

   6. 2100A Loop Mandatory Repeat 1

      1. 0300 · NM1 · Member Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 0400 · PER · Member Communications Numbers · Max 1 · Optional

         To identify a person or office to whom administrative communications should be directed

         When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
         Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send.

      3. 0500 · N3 · Member Residence Street Address · Max 1 · Optional

         To specify the location of the named party

         Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.

      4. 0600 · N4 · Member City, State, ZIP Code · Max 1 · Optional

         To specify the geographic place of the named party

         Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.

      5. 0800 · DMG · Member Demographics · Max 1 · Optional

         To supply demographic information

         Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send.

      6. 1000 · EC · Employment Class · Max >1 · Optional

         To provide class of employment information

         Required when sending additional employment class information on the member. If not required by this implementation guide, do not send.

      7. 1100 · ICM · Member Income · Max 1 · Optional

         To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions

         Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

      8. 1200 · AMT · Member Policy Amounts · Max 7 · Optional

         To indicate the total monetary amount

         Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

      9. 1300 · HLH · Member Health Information · Max 1 · Optional

         To provide health information

         Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send.

      10. 1500 · LUI · Member Language · Max >1 · Optional

          To specify language, type of usage, and proficiency or fluency

          Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.
          Any need to send/collect this information will need to be contained in the trading partner agreement.

   7. 2100B Loop Optional Repeat 1

      1. 0300 · NM1 · Incorrect Member Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.
         If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.

      2. 0800 · DMG · Incorrect Member Demographics · Max 1 · Optional

         To supply demographic information

         Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.

   8. 2100C Loop Optional Repeat 1

      1. 0300 · NM1 · Member Mailing Address · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send.

      2. 0500 · N3 · Member Mail Street Address · Max 1 · Mandatory

         To specify the location of the named party

      3. 0600 · N4 · Member Mail City, State, ZIP Code · Max 1 · Mandatory

         To specify the geographic place of the named party

   9. 2100D Loop Optional Repeat 3

      1. 0300 · NM1 · Member Employer · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.
         This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop.

      2. 0400 · PER · Member Employer Communications Numbers · Max 1 · Optional

         To identify a person or office to whom administrative communications should be directed

         When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
         Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send.

      3. 0500 · N3 · Member Employer Street Address · Max 1 · Optional

         To specify the location of the named party

         Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

      4. 0600 · N4 · Member Employer City, State, ZIP Code · Max 1 · Optional

         To specify the geographic place of the named party

         Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

   10. 2100E Loop Optional Repeat 3

       1. 0300 · NM1 · Member School · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.

       2. 0400 · PER · Member School Commmunications Numbers · Max 1 · Optional

          To identify a person or office to whom administrative communications should be directed

          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
          Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Member School Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Member School City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

   11. 2100F Loop Optional Repeat 1

       1. 0300 · NM1 · Custodial Parent · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.
          Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment.

       2. 0400 · PER · Custodial Parent Communications Numbers · Max 1 · Optional

          To identify a person or office to whom administrative communications should be directed

          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
          Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Custodial Parent Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Custodial Parent City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.

   12. 2100G Loop Optional Repeat 13

       1. 0300 · NM1 · Responsible Person · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send.

       2. 0400 · PER · Responsible Person Communications Numbers · Max 1 · Optional

          To identify a person or office to whom administrative communications should be directed

          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
          Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send.

       3. 0500 · N3 · Responsible Person Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.

       4. 0600 · N4 · Responsible Person City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.

   13. 2100H Loop Optional Repeat 1

       1. 0300 · NM1 · Drop Off Location · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

          Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.

       2. 0500 · N3 · Drop Off Location Street Address · Max 1 · Optional

          To specify the location of the named party

          Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.

       3. 0600 · N4 · Drop Off Location City, State, ZIP Code · Max 1 · Optional

          To specify the geographic place of the named party

          Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.

   14. 2200 Loop Optional Repeat >1

       1. 2000 · DSB · Disability Information · Max 1 · Mandatory

          To supply disability information

          Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send.

       2. 2100 · DTP · Disability Eligibility Dates · Max 2 · Optional

          To specify any or all of a date, a time, or a time period

          This segment is used to send the first and last date of disability.
          Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.

   15. 2300 Loop Optional Repeat 99

       1. 2600 · HD · Health Coverage · Max 1 · Mandatory

          To provide information on health coverage

          Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.
          Refer to section 1.4.4 "Termination" for additional information relative to removing a member's coverage.

       2. 2700 · DTP · Health Coverage Dates · Max 6 · Mandatory

          To specify any or all of a date, a time, or a time period

       3. 2800 · AMT · Health Coverage Policy · Max 9 · Optional

          To indicate the total monetary amount

          Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.

       4. 2900 · REF · Health Coverage Policy Number · Max 14 · Optional

          To specify identifying information

          Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send.

       5. 2900 · REF · Prior Coverage Months · Max 1 · Optional

          To specify identifying information

          Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act.

       6. 3000 · IDC · Identification Card · Max 3 · Optional

          To provide notification to produce replacement identification card(s)

          Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.
          An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card.

       7. 2310 Loop Optional Repeat 30

          1. 3100 · LX · Provider Information · Max 1 · Mandatory

             To reference a line number in a transaction set

             Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.
             Use one iteration of the loop to identify each applicable health care service provider.
             The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.

          2. 3200 · NM1 · Provider Name · Max 1 · Mandatory

             To supply the full name of an individual or organizational entity

             The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2.

          3. 3500 · N3 · Provider Address · Max 2 · Optional

             To specify the location of the named party

             Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.

          4. 3600 · N4 · Provider City, State, ZIP Code · Max 1 · Optional

             To specify the geographic place of the named party

             Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.

          5. 3700 · PER · Provider Communications Numbers · Max 2 · Optional

             To identify a person or office to whom administrative communications should be directed

             When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
             Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send.

          6. 3950 · PLA · Provider Change Reason · Max 1 · Optional

             To indicate action to be taken for the location specified and to qualify the location specified

             Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.

       8. 2320 Loop Optional Repeat 5

          1. 4000 · COB · Coordination of Benefits · Max 1 · Mandatory

             To supply information on coordination of benefits

             Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.

          2. 4050 · REF · Additional Coordination of Benefits Identifiers · Max 4 · Optional

             To specify identifying information

             Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
             Use the Social Security Number until the National ID Number for individuals is available.

          3. 4070 · DTP · Coordination of Benefits Eligibility Dates · Max 2 · Optional

             To specify any or all of a date, a time, or a time period

             Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send.

          4. 2330 Loop Optional Repeat 3

             1. 4100 · NM1 · Coordination of Benefits Related Entity · Max 1 · Mandatory

                To supply the full name of an individual or organizational entity

                Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send.

             2. 4300 · N3 · Coordination of Benefits Related Entity Address · Max 1 · Optional

                To specify the location of the named party

                Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.

             3. 4400 · N4 · Coordination of Benefits Other Insurance Company City, State, ZIP Code · Max 1 · Optional

                To specify the geographic place of the named party

                Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.

             4. 4500 · PER · Administrative Communications Contact · Max 1 · Optional

                To identify a person or office to whom administrative communications should be directed

                Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.

   16. 6880 · LS · Additional Reporting Categories · Max 1 · Optional

       To indicate that the next segment begins a loop

       Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.

   17. 2700 Loop Optional Repeat >1

       1. 6881 · LX · Member Reporting Categories · Max 1 · Mandatory

          To reference a line number in a transaction set

          Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.

       2. 2750 Loop Optional Repeat 1

          1. 6882 · N1 · Reporting Category · Max 1 · Mandatory

             To identify a party by type of organization, name, and code

             Required to specify the name of the reporting category of the member's participating entity.

          2. 6883 · REF · Reporting Category Reference · Max 1 · Optional

             To specify identifying information

             Required to specify the reference identifier associated with the reporting category of the member's participating entity.

          3. 6884 · DTP · Reporting Category Date · Max 1 · Optional

             To specify any or all of a date, a time, or a time period

             Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
             Use this segment to associate a date or date range with a reporting category.

   18. 6885 · LE · Additional Reporting Categories Loop Termination · Max 1 · Optional

       To indicate that the loop immediately preceding this segment is complete

       Required when the LS segment in position 6880 is sent. If not required by this implementation guide, do not send.

2. 6900 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)