x12 834 Benefit Enrollment and Maintenance
The x12 Transaction Set 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.
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.
ISA*00* *00* *12*ABCCOM *01*999999999 *101127*1719*U*00400*000003438*0*P~
N3*123 SAMPLE RD~