EDI
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834 Benefit Enrollment and Maintenance

Functional Group BE

X12N Insurance Subcommittee

This Draft Standard for Trial Use 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

Sequence
Segment
Name
Max use
010
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
020
Beginning SegmentMandatory
Max 1
To indicate the beginning of a transaction set
030
Reference IdentificationMandatory
Max >1
To specify identifying information
The REF segment is mandatory as it contains the policy number that pertains to the enrollment data in the transaction set. The twenty occurrences allow for different policy numbers per product line.
040
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
050
Monetary Amount
Max >1
To indicate the total monetary amount
The AMT segment is used to record the total Flexible Spending Account contributions in the transaction set.
060
Quantity
Max >1
To specify quantity information
The QTY segment is used to record the total number of subscribers and dependents in the transaction set.
1000 Loop
Repeat >1
070
NameMandatory
Max 1
To identify a party by type of organization, name, and code
At least one iteration of the N1 loop is required to identify the sender or receiver.
080
Additional Name Information
Max 2
To specify additional names or those longer than 35 characters in length
090
Address Information
Max 2
To specify the location of the named party
100
Geographic Location
Max 1
To specify the geographic place of the named party
110
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
1100 Loop
Repeat 10
120
Account IdentificationMandatory
Max 1
To specify account information
130
Reference Identification
Max 5
To specify identifying information
140
Address Information
Max 1
To specify the location of the named party
150
Geographic Location
Max 1
To specify the geographic place of the named party
160
Administrative Communications Contact
Max 5
To identify a person or office to whom administrative communications should be directed
170
Date or Time or Period
Max 1
To specify any or all of a date, a time, or a time period
180
Monetary Amount
Max 1
To indicate the total monetary amount

Detail

Sequence
Segment
Name
Max use
2000 Loop
Repeat >1
010
Insured BenefitMandatory
Max 1
To provide benefit information on insured entities
A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information.
020
Reference IdentificationMandatory
Max >1
To specify identifying information
The REF segment is required to link the dependent(s) to the subscriber.
030
Individual or Organizational Name
Max 2
To supply the full name of an individual or organizational entity
040
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
050
Address Information
Max 2
To specify the location of the named party
The N3 and N4 segments within the INS loop are used to report the address of the subscriber or the dependent.
060
Geographic Location
Max 1
To specify the geographic place of the named party
080
Demographic Information
Max 1
To supply demographic information
090
Electronic Funds Transfer Information
Max 1
To supply information on the electronic funds transfer (EFT) method of payment
100
Employment Class
Max >1
To provide class of employment information
110
Individual Income
Max 1
To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions
120
Monetary Amount
Max 10
To indicate the total monetary amount
130
Health Information
Max 1
To provide health information
140
Health Care Information Codes
Max 10
To supply information related to the delivery of health care
2100 Loop
Repeat 2
160
NameMandatory
Max 1
To identify a party by type of organization, name, and code
The N1 loop may only appear for a Dependent to report school and or employment information.
170
Date or Time or Period
Max 1
To specify any or all of a date, a time, or a time period
180
Address Information
Max 1
To specify the location of the named party
The N3 and N4 segments are used to report the address of the school or the employer.
190
Geographic Location
Max 1
To specify the geographic place of the named party
2200 Loop
Repeat 4
200
Disability InformationMandatory
Max 1
To supply disability information
The DSB loop may only appear for the Subscriber.
210
Date or Time or Period
Max 10
To specify any or all of a date, a time, or a time period
220
Adjustment Amount
Max 10
To specify the characteristics of an adjustment
2300 Loop
Repeat 10
230
Administrative Communications ContactMandatory
Max 1
To identify a person or office to whom administrative communications should be directed
240
Address Information
Max 1
To specify the location of the named party
The N3 and N4 segments are used to report the address of the responsible person and or the emergency contact.
250
Geographic Location
Max 1
To specify the geographic place of the named party
2400 Loop
Repeat 99
260
Health CoverageMandatory
Max 1
To provide information on health coverage
270
Date or Time or Period
Max 10
To specify any or all of a date, a time, or a time period
280
Monetary Amount
Max 3
To indicate the total monetary amount
290
Reference Identification
Max 5
To specify identifying information
300
Identification Card
Max >1
To provide notification to produce replacement identification card(s)
2410 Loop
Repeat 30
310
Assigned NumberMandatory
Max 1
To reference a line number in a transaction set
The LX loop contains information about the primary care providers for the subscriber or the dependent, and about the beneficiaries of any employer-sponsored life insurance for the subscriber.
320
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
Either NM1 or N1 will be included depending on whether an individual or organization is being specified.
330
Name
Max 3
To identify a party by type of organization, name, and code
340
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
350
Address Information
Max 2
To specify the location of the named party
360
Geographic Location
Max 2
To specify the geographic place of the named party
370
Administrative Communications Contact
Max 2
To identify a person or office to whom administrative communications should be directed
380
Provider Information
Max 1
To specify the identifying characteristics of a provider
390
Date or Time or Period
Max 6
To specify any or all of a date, a time, or a time period
2420 Loop
Repeat 5
400
Coordination of BenefitsMandatory
Max 1
To supply information on coordination of benefits
405
Reference Identification
Max >1
To specify identifying information
410
Name
Max 1
To identify a party by type of organization, name, and code
420
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
430
Address Information
Max 2
To specify the location of the named party
440
Geographic Location
Max 1
To specify the geographic place of the named party
450
Date or Time or Period
Max 2
To specify any or all of a date, a time, or a time period
2500 Loop
Repeat 10
460
Life CoverageMandatory
Max 1
To provide information on life coverage
470
Monetary Amount
Max 5
To indicate the total monetary amount
480
Date or Time or Period
Max 2
To specify any or all of a date, a time, or a time period
2510 Loop
Repeat 20
490
Beneficiary or Owner InformationMandatory
Max 1
To supply beneficiary, co-participant, and owner information
500
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
510
Name
Max 1
To identify a party by type of organization, name, and code
520
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
530
Address Information
Max 1
To specify the location of the named party
540
Geographic Location
Max 1
To specify the geographic place of the named party
542
Demographic Information
Max 1
To supply demographic information
2600 Loop
Repeat 5
550
Flexible Spending AccountMandatory
Max 1
To supply flexible spending account information
The FSA loop may only appear for the Subscriber.
560
Monetary Amount
Max 10
To indicate the total monetary amount
570
Date or Time or Period
Max 10
To specify any or all of a date, a time, or a time period
2700 Loop
Repeat >1
580
Retirement ProductMandatory
Max 1
To specify the retirement product characteristics
590
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
592
Reference Identification
Max >1
To specify identifying information
594
Investment Vehicle Selection
Max >1
To specify type of investment vehicle or account and other basic data about the investment
596
Monetary Amount
Max 20
To indicate the total monetary amount
597
Quantity
Max 20
To specify quantity information
598
File Information
Max 3
To transmit a fixed-format record or matrix contents
600
Relationship
Max 1
To specify relationship and birth order of entity
2710 Loop
Repeat >1
610
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
630
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
651
Demographic Information
Max 1
To supply demographic information
652
Beneficiary or Owner Information
Max 1
To supply beneficiary, co-participant, and owner information
653
Reference Identification
Max >1
To specify identifying information
2720 Loop
Repeat >1
654
Property or Entity IdentificationMandatory
Max 1
To define the attributes of a property or an entity
655
Address Information
Max 1
To specify the location of the named party
656
Geographic Location
Max 1
To specify the geographic place of the named party
657
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
2730 Loop
Repeat >1
660
Financial ContributionMandatory
Max 1
To specify the financial contribution information
670
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
2740 Loop
Repeat >1
678
Investment Vehicle SelectionMandatory
Max 1
To specify type of investment vehicle or account and other basic data about the investment
679
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
680
Quantity
Max >1
To specify quantity information
681
Entity
Max >1
To designate the entities which are parties to a transaction and specify a reference meaningful to those entities
682
Reference Identification
Max >1
To specify identifying information
683
Monetary Amount
Max 20
To indicate the total monetary amount
684
File Information
Max 3
To transmit a fixed-format record or matrix contents
2750 Loop
Repeat >1
685
IncomeMandatory
Max 1
To provide type and amount of income obtained
686
Quantity
Max >1
To specify quantity information
687
Date or Time or Period
Max >1
To specify any or all of a date, a time, or a time period
690
Transaction Set TrailerMandatory
Max 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.