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

Position
Segment
Name
Max use
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
Beginning SegmentMandatory
Max 1
To indicate the beginning of a transaction set
0300
Reference IdentificationOptional
Max >1
To specify identifying information
0400
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
0500
Monetary AmountOptional
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.
0600
QuantityOptional
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
0700
NameMandatory
Max 1
To identify a party by type of organization, name, and code
At least one iteration of loop 1000 is required to identify the sender or receiver.
0900
Address InformationOptional
Max 2
To specify the location of the named party
1000
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
1100
Administrative Communications ContactOptional
Max 3
To identify a person or office to whom administrative communications should be directed
1100 Loop
Repeat 10
1200
Account IdentificationMandatory
Max 1
To specify account information
1300
Reference IdentificationOptional
Max 5
To specify identifying information
1400
Address InformationOptional
Max 1
To specify the location of the named party
1500
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
1600
Administrative Communications ContactOptional
Max 5
To identify a person or office to whom administrative communications should be directed
1700
Date or Time or PeriodOptional
Max 1
To specify any or all of a date, a time, or a time period
1800
Monetary AmountOptional
Max 1
To indicate the total monetary amount

Detail

Position
Segment
Name
Max use
2000 Loop
Repeat >1
0100
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.
0200
Reference IdentificationMandatory
Max >1
To specify identifying information
The REF segment is required to link the dependent(s) to the subscriber.
0250
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
2100 Loop
Repeat >1
0300
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
0400
Administrative Communications ContactOptional
Max 1
To identify a person or office to whom administrative communications should be directed
0500
Address InformationOptional
Max 1
To specify the location of the named party
0600
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
0800
Demographic InformationOptional
Max 1
To supply demographic information
0900
Electronic Funds Transfer InformationOptional
Max 1
To supply information on the electronic funds transfer (EFT) method of payment
1000
Employment ClassOptional
Max >1
To provide class of employment information
1100
Individual IncomeOptional
Max 1
To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions
1200
Monetary AmountOptional
Max 10
To indicate the total monetary amount
1300
Health InformationOptional
Max 1
To provide health information
1400
Health Care Information CodesOptional
Max 10
To supply information related to the delivery of health care
1500
Language UseOptional
Max >1
To specify language, type of usage, and proficiency or fluency
2200 Loop
Repeat 4
2000
Disability InformationMandatory
Max 1
To supply disability information
2100
Date or Time or PeriodOptional
Max 10
To specify any or all of a date, a time, or a time period
2200
Adjustment AmountOptional
Max 10
To specify the characteristics of an adjustment
2300 Loop
Repeat 99
2600
Health CoverageMandatory
Max 1
To provide information on health coverage
2700
Date or Time or PeriodOptional
Max 10
To specify any or all of a date, a time, or a time period
2800
Monetary AmountOptional
Max 3
To indicate the total monetary amount
2900
Reference IdentificationOptional
Max 5
To specify identifying information
3000
Identification CardOptional
Max >1
To provide notification to produce replacement identification card(s)
2310 Loop
Repeat 30
3100
Assigned NumberMandatory
Max 1
To reference a line number in a transaction set
Loop 2310 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.
3200
Individual or Organizational NameOptional
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.
3300
NameOptional
Max 3
To identify a party by type of organization, name, and code
3500
Address InformationOptional
Max 2
To specify the location of the named party
3600
Geographic LocationOptional
Max 2
To specify the geographic place of the named party
3700
Administrative Communications ContactOptional
Max 2
To identify a person or office to whom administrative communications should be directed
3800
Provider InformationOptional
Max 1
To specify the identifying characteristics of a provider
3900
Date or Time or PeriodOptional
Max 6
To specify any or all of a date, a time, or a time period
3950
Place or LocationOptional
Max 1
To indicate action to be taken for the location specified and to qualify the location specified
2320 Loop
Repeat 5
4000
Coordination of BenefitsMandatory
Max 1
To supply information on coordination of benefits
4050
Reference IdentificationOptional
Max >1
To specify identifying information
4070
Date or Time or PeriodOptional
Max 2
To specify any or all of a date, a time, or a time period
2330 Loop
Repeat 3
4100
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
4300
Address InformationOptional
Max 2
To specify the location of the named party
4400
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
4500
Administrative Communications ContactOptional
Max 1
To identify a person or office to whom administrative communications should be directed
2400 Loop
Repeat 10
4600
Life CoverageMandatory
Max 1
To provide information on life coverage
4700
Monetary AmountOptional
Max 5
To indicate the total monetary amount
4800
Date or Time or PeriodOptional
Max 2
To specify any or all of a date, a time, or a time period
4850
Reference IdentificationOptional
Max >1
To specify identifying information
2410 Loop
Repeat 20
4900
Beneficiary or Owner InformationMandatory
Max 1
To supply beneficiary, co-participant, and owner information
5000
Individual or Organizational NameOptional
Max 1
To supply the full name of an individual or organizational entity
5100
NameOptional
Max 1
To identify a party by type of organization, name, and code
5300
Address InformationOptional
Max 1
To specify the location of the named party
5400
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
5420
Demographic InformationOptional
Max 1
To supply demographic information
2500 Loop
Repeat 5
5500
Flexible Spending AccountMandatory
Max 1
To supply flexible spending account information
Loop 2500 may only appear for the Subscriber.
5600
Monetary AmountOptional
Max 10
To indicate the total monetary amount
5700
Date or Time or PeriodOptional
Max 10
To specify any or all of a date, a time, or a time period
5750
Reference IdentificationOptional
Max >1
To specify identifying information
2600 Loop
Repeat >1
5800
Retirement ProductMandatory
Max 1
To specify the retirement product characteristics
5900
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
5920
Reference IdentificationOptional
Max >1
To specify identifying information
5940
Investment Vehicle SelectionOptional
Max >1
To specify type of investment vehicle or account and other basic data about the investment
5960
Monetary AmountOptional
Max 20
To indicate the total monetary amount
5970
QuantityOptional
Max 20
To specify quantity information
5980
File InformationOptional
Max 3
To transmit a fixed-format record or matrix contents
6000
RelationshipOptional
Max 1
To specify relationship and birth order of entity
2610 Loop
Repeat >1
6100
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
6510
Demographic InformationOptional
Max 1
To supply demographic information
6520
Beneficiary or Owner InformationOptional
Max 1
To supply beneficiary, co-participant, and owner information
6530
Reference IdentificationOptional
Max >1
To specify identifying information
2620 Loop
Repeat >1
6540
Property or Entity IdentificationMandatory
Max 1
To define the attributes of a property or an entity
6550
Address InformationOptional
Max 1
To specify the location of the named party
6560
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
6570
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
2630 Loop
Repeat >1
6600
Financial ContributionMandatory
Max 1
To specify the financial contribution information
6700
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
2640 Loop
Repeat >1
6780
Investment Vehicle SelectionMandatory
Max 1
To specify type of investment vehicle or account and other basic data about the investment
6790
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
6800
QuantityOptional
Max >1
To specify quantity information
6810
EntityOptional
Max >1
To designate the entities which are parties to a transaction and specify a reference meaningful to those entities
6820
Reference IdentificationOptional
Max >1
To specify identifying information
6830
Monetary AmountOptional
Max 20
To indicate the total monetary amount
6840
File InformationOptional
Max 3
To transmit a fixed-format record or matrix contents
2650 Loop
Repeat >1
6850
IncomeMandatory
Max 1
To provide type and amount of income obtained
6860
QuantityOptional
Max >1
To specify quantity information
6870
Date or Time or PeriodOptional
Max >1
To specify any or all of a date, a time, or a time period
6900
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)

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