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EDI 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) to be used 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 numbers.

    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.
  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. N1 Loop Mandatory
    Repeat 10
    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.
    2. To specify additional names or those longer than 35 characters in length

    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. ACT Loop Optional
      Repeat 2
      1. To specify account information.

      2. To specify identifying numbers.

      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. INS Loop Mandatory
    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 numbers.

      The REF segment is required to link the dependent(s) to the subscriber.
    3. To supply the full name of an individual or organizational entity

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

    5. 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.
    6. To specify the geographic place of the named party

    7. To supply demographic information

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

    9. To provide class of employment information

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

    11. To indicate the total monetary amount.

    12. To provide health information

    13. To provide characteristics that may have multiple values

      The CD2 segment is used to record Pre-existing Conditions.
    14. N1 Loop Optional
      Repeat 2
      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.
      2. To specify any or all of a date, a time, or a time period

      3. 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.
      4. To specify the geographic place of the named party

    15. DSB Loop Optional
      Repeat 4
      1. To supply disability information

        The DSB loop may only appear for the Subscriber.
      2. To specify any or all of a date, a time, or a time period

      3. To specify the characteristics of an adjustment

    16. PER Loop Optional
      Repeat 10
      1. To identify a person or office to whom administrative communications should be directed

      2. 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.
      3. To specify the geographic place of the named party

    17. HD 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 numbers.

      5. To provide notification to produce replacement identification card

      6. LX Loop Optional
        Repeat 30
        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.
        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 or those longer than 35 characters in length

        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

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

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

        3. To specify additional names or those longer than 35 characters in length

        4. To specify the location of the named party

        5. To specify the geographic place of the named party

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

    18. LC 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. BEN 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 or those longer than 35 characters in length

        5. To specify the location of the named party

        6. To specify the geographic place of the named party

        7. To supply demographic information

    19. FSA Loop Optional
      Repeat 5
      1. To supply flexible spending account information

        The FSA loop 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

    20. RP 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 numbers.

      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

      8. NM1 Loop Optional
        Repeat >1
        1. To supply the full name of an individual or organizational entity

        2. To specify additional names or those longer than 35 characters in length

        3. To supply demographic information

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

        5. To specify identifying numbers.

        6. NX1 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

      9. FC 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. INV 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 numbers.

          6. To indicate the total monetary amount.

          7. To transmit a fixed format record

      10. AIN 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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