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.