EDI 834 X220A1 - Benefit Enrollment and Maintenance
Functional Group BE
X12N Insurance Subcommittee
This 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.
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
- 0100Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 0200Beginning SegmentMandatoryMax 1
To indicate the beginning of a transaction set
- 0300Transaction Set Policy NumberOptionalMax 1
To specify identifying information
The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set. - 0400File Effective DateOptionalMax >1
To specify any or all of a date, a time, or a time period
Required when specified in the contract. If not required by this implementation guide, do not send. - 0600Transaction Set Control TotalsOptionalMax 3
To specify quantity information
Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send. - 1000A Loop MandatoryRepeat 1
- 0700Sponsor NameMandatoryMax 1
To identify a party by type of organization, name, and code
This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
- 0700Sponsor NameMandatoryMax 1
- 1000B Loop MandatoryRepeat 1
- 0700PayerMandatoryMax 1
To identify a party by type of organization, name, and code
This loop identifies the payer. See section 1.5 for the definition of payer.
- 0700PayerMandatoryMax 1
- 1000C Loop OptionalRepeat 2
- 0700TPA/Broker NameMandatoryMax 1
To identify a party by type of organization, name, and code
Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send. - 1100C Loop OptionalRepeat 1
- 1200TPA/Broker Account InformationMandatoryMax 1
To specify account information
Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.
- 1200TPA/Broker Account InformationMandatoryMax 1
- 0700TPA/Broker NameMandatoryMax 1
Detail
- 2000 Loop MandatoryRepeat >1
- 0100Member Level DetailMandatoryMax 1
To provide benefit information on insured entities
Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission. - 0200Subscriber IdentifierMandatoryMax 1
To specify identifying information
This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available. - 0200Member Policy NumberOptionalMax 1
To specify identifying information
The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send. - 0200Member Supplemental IdentifierOptionalMax 13
To specify identifying information
Required when sending additional identifying information on the member. If not required by this implementation guide, do not send. - 0250Member Level DatesOptionalMax 24
To specify any or all of a date, a time, or a time period
Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective. - 2100A Loop MandatoryRepeat 1
- 0300Member NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 0400Member Communications NumbersOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send. - 0500Member Residence Street AddressOptionalMax 1
To specify the location of the named party
Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send. - 0600Member City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send. - 0800Member DemographicsOptionalMax 1
To supply demographic information
Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send. - 1000Employment ClassOptionalMax >1
To provide class of employment information
Required when sending additional employment class information on the member. If not required by this implementation guide, do not send. - 1100Member IncomeOptionalMax 1
To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions
Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send. - 1200Member Policy AmountsOptionalMax 7
To indicate the total monetary amount
Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send. - 1300Member Health InformationOptionalMax 1
To provide health information
Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send. - 1500Member LanguageOptionalMax >1
To specify language, type of usage, and proficiency or fluency
Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.Any need to send/collect this information will need to be contained in the trading partner agreement.
- 0300Member NameMandatoryMax 1
- 2100B Loop OptionalRepeat 1
- 0300Incorrect Member NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. - 0800Incorrect Member DemographicsOptionalMax 1
To supply demographic information
Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.
- 0300Incorrect Member NameMandatoryMax 1
- 2100C Loop OptionalRepeat 1
- 0300Member Mailing AddressMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send. - 0500Member Mail Street AddressMandatoryMax 1
To specify the location of the named party
- 0600Member Mail City, State, ZIP CodeMandatoryMax 1
To specify the geographic place of the named party
- 0300Member Mailing AddressMandatoryMax 1
- 2100D Loop OptionalRepeat 3
- 0300Member EmployerMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop. - 0400Member Employer Communications NumbersOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send. - 0500Member Employer Street AddressOptionalMax 1
To specify the location of the named party
Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send. - 0600Member Employer City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
- 0300Member EmployerMandatoryMax 1
- 2100E Loop OptionalRepeat 3
- 0300Member SchoolMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send. - 0400Member School Commmunications NumbersOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send. - 0500Member School Street AddressOptionalMax 1
To specify the location of the named party
Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send. - 0600Member School City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
- 0300Member SchoolMandatoryMax 1
- 2100F Loop OptionalRepeat 1
- 0300Custodial ParentMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment. - 0400Custodial Parent Communications NumbersOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send. - 0500Custodial Parent Street AddressOptionalMax 1
To specify the location of the named party
Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send. - 0600Custodial Parent City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
- 0300Custodial ParentMandatoryMax 1
- 2100G Loop OptionalRepeat 13
- 0300Responsible PersonMandatoryMax 1
To supply the full name of an individual or organizational entity
Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send. - 0400Responsible Person Communications NumbersOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send. - 0500Responsible Person Street AddressOptionalMax 1
To specify the location of the named party
Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send. - 0600Responsible Person City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
- 0300Responsible PersonMandatoryMax 1
- 2100H Loop OptionalRepeat 1
- 0300Drop Off LocationMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send. - 0500Drop Off Location Street AddressOptionalMax 1
To specify the location of the named party
Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send. - 0600Drop Off Location City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
- 0300Drop Off LocationMandatoryMax 1
- 2200 Loop OptionalRepeat >1
- 2000Disability InformationMandatoryMax 1
To supply disability information
Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send. - 2100Disability Eligibility DatesOptionalMax 2
To specify any or all of a date, a time, or a time period
This segment is used to send the first and last date of disability.Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.
- 2000Disability InformationMandatoryMax 1
- 2300 Loop OptionalRepeat 99
- 2600Health CoverageMandatoryMax 1
To provide information on health coverage
Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.Refer to section 1.4.4 "Termination" for additional information relative to removing a member's coverage. - 2700Health Coverage DatesMandatoryMax 6
To specify any or all of a date, a time, or a time period
- 2800Health Coverage PolicyOptionalMax 9
To indicate the total monetary amount
Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send. - 2900Health Coverage Policy NumberOptionalMax 14
To specify identifying information
Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send. - 2900Prior Coverage MonthsOptionalMax 1
To specify identifying information
Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act. - 3000Identification CardOptionalMax 3
To provide notification to produce replacement identification card(s)
Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card. - 2310 Loop OptionalRepeat 30
- 3100Provider InformationMandatoryMax 1
To reference a line number in a transaction set
Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.Use one iteration of the loop to identify each applicable health care service provider.The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change. - 3200Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2. - 3500Provider AddressOptionalMax 2
To specify the location of the named party
Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send. - 3600Provider City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send. - 3700Provider Communications NumbersOptionalMax 2
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send. - 3950Provider Change ReasonOptionalMax 1
To indicate action to be taken for the location specified and to qualify the location specified
Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.
- 3100Provider InformationMandatoryMax 1
- 2320 Loop OptionalRepeat 5
- 4000Coordination of BenefitsMandatoryMax 1
To supply information on coordination of benefits
Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send. - 4050Additional Coordination of Benefits IdentifiersOptionalMax 4
To specify identifying information
Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.Use the Social Security Number until the National ID Number for individuals is available. - 4070Coordination of Benefits Eligibility DatesOptionalMax 2
To specify any or all of a date, a time, or a time period
Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send. - 2330 Loop OptionalRepeat 3
- 4100Coordination of Benefits Related EntityMandatoryMax 1
To supply the full name of an individual or organizational entity
Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send. - 4300Coordination of Benefits Related Entity AddressOptionalMax 1
To specify the location of the named party
Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send. - 4400Coordination of Benefits Other Insurance Company City, State, ZIP CodeOptionalMax 1
To specify the geographic place of the named party
Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send. - 4500Administrative Communications ContactOptionalMax 1
To identify a person or office to whom administrative communications should be directed
Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
- 4100Coordination of Benefits Related EntityMandatoryMax 1
- 4000Coordination of BenefitsMandatoryMax 1
- 2600Health CoverageMandatoryMax 1
- 6880Additional Reporting CategoriesOptionalMax 1
To indicate that the next segment begins a loop
Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send. - 2700 Loop OptionalRepeat >1
- 6881Member Reporting CategoriesMandatoryMax 1
To reference a line number in a transaction set
Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send. - 2750 Loop OptionalRepeat 1
- 6882Reporting CategoryMandatoryMax 1
To identify a party by type of organization, name, and code
Required to specify the name of the reporting category of the member's participating entity. - 6883Reporting Category ReferenceOptionalMax 1
To specify identifying information
Required to specify the reference identifier associated with the reporting category of the member's participating entity. - 6884Reporting Category DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.Use this segment to associate a date or date range with a reporting category.
- 6882Reporting CategoryMandatoryMax 1
- 6881Member Reporting CategoriesMandatoryMax 1
- 6885Additional Reporting Categories Loop TerminationOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
Required when the LS segment in position 6880 is sent. If not required by this implementation guide, do not send.
- 0100Member Level DetailMandatoryMax 1
- 6900Transaction Set TrailerMandatoryMax 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)