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

  2. To indicate the beginning of a transaction set

  3. To specify identifying information

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

  5. To indicate the total monetary amount

    The AMT segment is used to record the total Flexible Spending Account contributions in the transaction set.
  6. To specify quantity information

    The QTY segment is used to record the total number of subscribers and dependents in the transaction set.
  7. 1000 Loop Mandatory
    Repeat >1
    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.
    2. To specify additional names

    3. To specify the location of the named party

    4. To specify the geographic place of the named party

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

    6. 1100 Loop Optional
      Repeat 10
      1. To specify account information

      2. To specify identifying information

      3. To specify the location of the named party

      4. To specify the geographic place of the named party

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

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

      7. To indicate the total monetary amount

Detail

Position
Segment
Name
Max use
  1. 2000 Loop Optional
    Repeat >1
    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.
    2. To specify identifying information

      The REF segment is required to link the dependent(s) to the subscriber.
    3. To specify any or all of a date, a time, or a time period

    4. 2100 Loop Optional
      Repeat >1
      1. To supply the full name of an individual or organizational entity

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

      3. To specify the location of the named party

      4. To specify the geographic place of the named party

      5. To supply demographic information

      6. To supply information on the electronic funds transfer (EFT) method of payment

      7. To provide class of employment information

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

      9. To indicate the total monetary amount

      10. To provide health information

      11. To supply information related to the delivery of health care

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

    5. 2200 Loop Optional
      Repeat 4
      1. To supply disability information

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

      3. To specify the characteristics of an adjustment

    6. 2300 Loop Optional
      Repeat 99
      1. To provide information on health coverage

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

      3. To indicate the total monetary amount

      4. To specify identifying information

      5. To provide notification to produce replacement identification card(s)

      6. 2310 Loop Optional
        Repeat 30
        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.
        2. 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.
        3. To identify a party by type of organization, name, and code

        4. To specify additional names

        5. To specify the location of the named party

        6. To specify the geographic place of the named party

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

        8. To specify the identifying characteristics of a provider

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

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

      7. 2320 Loop Optional
        Repeat 5
        1. To supply information on coordination of benefits

        2. To specify identifying information

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

        4. 2330 Loop Optional
          Repeat 3
          1. To supply the full name of an individual or organizational entity

          2. To specify additional names

          3. To specify the location of the named party

          4. To specify the geographic place of the named party

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

    7. 2400 Loop Optional
      Repeat 10
      1. To provide information on life coverage

      2. To indicate the total monetary amount

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

      4. To specify identifying information

      5. 2410 Loop Optional
        Repeat 20
        1. To supply beneficiary, co-participant, and owner information

        2. To supply the full name of an individual or organizational entity

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

        4. To specify additional names

        5. To specify the location of the named party

        6. To specify the geographic place of the named party

        7. To supply demographic information

    8. 2500 Loop Optional
      Repeat 5
      1. To supply flexible spending account information

        Loop 2500 may only appear for the Subscriber.
      2. To indicate the total monetary amount

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

      4. To specify identifying information

    9. 2600 Loop Optional
      Repeat >1
      1. To specify the retirement product characteristics

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

      3. To specify identifying information

      4. To specify type of investment vehicle or account and other basic data about the investment

      5. To indicate the total monetary amount

      6. To specify quantity information

      7. To transmit a fixed-format record or matrix contents

      8. To specify relationship and birth order of entity

      9. 2610 Loop Optional
        Repeat >1
        1. To supply the full name of an individual or organizational entity

        2. To specify additional names

        3. To supply demographic information

        4. To supply beneficiary, co-participant, and owner information

        5. To specify identifying information

        6. 2620 Loop Optional
          Repeat >1
          1. To define the attributes of a property or an entity

          2. To specify the location of the named party

          3. To specify the geographic place of the named party

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

      10. 2630 Loop Optional
        Repeat >1
        1. To specify the financial contribution information

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

        3. 2640 Loop Optional
          Repeat >1
          1. To specify type of investment vehicle or account and other basic data about the investment

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

          3. To specify quantity information

          4. To designate the entities which are parties to a transaction and specify a reference meaningful to those entities

          5. To specify identifying information

          6. To indicate the total monetary amount

          7. To transmit a fixed-format record or matrix contents

      11. 2650 Loop Optional
        Repeat >1
        1. To provide type and amount of income obtained

        2. To specify quantity information

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

  2. 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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