EDI 834 Benefit Enrollment and Maintenance
What is the EDI 834 Transaction Set?
The EDI 834 transaction set and format has been specified by HIPAA 5010 standards for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information. The EDI 834 transaction set may be used for any of the following functions relative to health plans: new enrollments, changes in a member’s enrollment, reinstatement of a member’s enrollment, disenrollment of members (i.e., termination of plan membership).
The EDI 834 A1 can be used to establish communication between the sponsor of the insurance product and the payer. 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. Such transaction(s) may or may not take place through a third party administrator (TPA).
In EDI 834 A1, the payer refers to an entity that pays claims, administers the insurance product or benefit, or both. The payer may be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, etc.) or an entity such as a third party administrator (TPA) or third party organization (TPO) that may be contracted by one of those groups.
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.
Read our EDI 834 case studies: EDI 834 and EDI 837 Claims Integration or the Rapid EDI 834 Integration with a Team of 2.
EDI 834 Benefit Enrollment in Data Mapper
(Click to enlarge)
How to Convert CSV, XLS or TXT Formats
to an EDI 834 Transaction
EDI 834 Frequently Asked Questions
Integration typically involves mapping the EDI 834 file to your internal enrollment system or database using an EDI integration engine such as the eiPlatform.
Yes, though the structure must remain compliant with X12 standards, custom fields and specific business rules can be added based on trading partner agreements.
The EDI 834 includes secure data formats and protocols to ensure the privacy and security of personal health information (PHI) as mandated by HIPAA.
Yes, you can watch our detailed product demonstration by clicking here. This video showcases how to efficiently convert CSV, XLS, or TXT formats into EDI 834 using the PilotFish platform.
Check out our EDI FAQ pages for more.
EDI 834 A1 Format Example
Business Case Scenario 1 – Enroll an Employee in Multiple Healthcare Insurance Products
ASC X12 Version: 005010 | Transaction Set: 834 | TR3 ID: 005010X22
John Doe is enrolling in three healthcare products – health, dental, and vision. He also has Coordination of Benefits (COB) with another insurance company.
Transmission Explanation
Table 1
| ST*834*12345*005010X220A1~ | Used to indicate the start of a transaction set and to specify a transaction set control number. |
| BGN*00*12456*19980520*1200****2~ | This is an original transaction uniquely identified by the sender with reference #12456. The transaction was created on 5/20/1998 at 12:00 Noon. |
| N1*P5**FI*999888777~ | Specifies the sponsor/sender’s tax ID number. |
| N1*IN**FI*654456654~ | Specifies the insurance company/receiver’s tax ID number. |
Table 2
| INS*Y*18*021*20*A***FT~ | Beginning of Table 2. Indicates that the subscriber (John Doe) is adding coverage as an active employee. |
| REF*0F*123456789~ | John’s subscriber ID number. |
| REF*1L*123456001~ | This is the group number assigned by the carrier. |
| DTP*356*D8*19960523~ | The eligibility date for this transaction is 5/23/1996. |
| NM1*IL*1*DOE*JOHN*P***34*123456789~ | Subscriber’s name. |
| PER*IP**HP*7172343334*WP*7172341240~ | John’s home phone number is (717)234-3334 and his work number is (717) 234-1240. |
| N3*100 MARKET ST*APT 3G~ | This is John’s street address. |
| N4*CAMP HILL*PA*17011**CY*CUMBERLAND~ | This is John’s city, state zip code and county. |
| DMG*D8*19400816*M~ | This is John’s date of birth and gender. |
| HD*021**HLT~ | John is enrolling in a health benefit. |
| DTP*348*D8*19960601~ | The benefits under this plan begin 6/01/1996. |
| COB*P*890111*5~ | This lets the carrier know that John has COB with another company. |
| HD*021**DEN~ | John is enrolling in the Dental benefit. |
| DTP*348*D8*19960601~ | The benefits under this plan begin 6/01/1996. |
| HD*021**VIS~ | John is enrolling in the Vision benefit. |
| DTP*348*D8*19960601~ | The benefits under this plan begin 6/01/1996. |
| SE*21*12345~ | End of transaction set. 21 segments were sent and the control number in the ST segment is 12345. |
Source
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.