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EDI 834 A1 Format Example

EDI 834 A1 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.

EDI 834 A1 Benefit Enrollment & Maintenance Transaction Displayed in EDI Data Processing Software

 

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.

HL7 is the registered trademark of Health Level Seven International. X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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