x12 834 Benefit Enrollment and Maintenance

834 Specifications

The EDI 834 transaction set represents a Benefit Enrollment and Maintenance document. It is used by employers, as well as unions, government agencies or insurance agencies, to enroll members in a healthcare benefit plan. The 834 has been specified by HIPAA 5010 standards for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information.

The 834 transaction 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 information is submitted, typically by the employer, to healthcare payer organizations who are responsible for payment of health claims and administering insurance and/or benefits. This may include insurance companies, healthcare professional organizations such as HMOs or PPOs, government agencies such as Medicare and Medicaid.

A typical 834 document may include the following information:

⇰ Subscriber name and identification
⇰ Plan network identification
⇰ Subscriber eligibility and/or benefit information
⇰ Product/service identification

The recipient of an 834 transaction must respond with a 999 Implementation Acknowledgement, which confirms that the file was received and provides feedback on the acceptance of the document.

834 Example

ISA*00* *00* *12*ABCCOM *01*999999999 *101127*1719*U*00400*000003438*0*P~
GS*PO*4405197800*999999999*20101127*1719*1421*X*004010~
ST*834*0179~
BGN*00*1*20050315*110650****4~
REF*38*SAMPLE_POLICY_NUMBER~
DTP*303*D8*20080321~
N1*P5*COMPAN_NAME*FI*000000000~
INS*Y*18*030*20*A~
REF*0F*SUBSCRIBER_NUMBER~
NM1*IL*1*JOHN DOE*R***34*1*0000000~
PER*IP**HP*2138051111~
N3*123 SAMPLE RD~
N4*CITY*ST*12345~
DMG*D8*19690101 *F~
HD*030~
DTP*348*D8*20080101~
REF*1L*INDIV_POLICY_NO~
SE*16*0179~
GE*1*1421~
IEA*1*000003438~


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