EDI 834 Benefit Enrollment and Maintenance

Functional Group BE

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) to be used 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

1. 010 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 020 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set.

3. 030 · REF · Reference Numbers · Max >1 · Mandatory

   To specify identifying numbers.

   The REF segment is mandatory as it contains the policy number that pertains to the enrollment data in the transaction set. The twenty occurrences allow for different policy numbers per product line.

4. 040 · DTP · Date or Time or Period · Max >1 · Optional

   To specify any or all of a date, a time, or a time period

5. 050 · AMT · Monetary Amount · Max >1 · Optional

   To indicate the total monetary amount.

   The AMT segment is used to record the total Flexible Spending Account contributions in the transaction set.

6. 060 · QTY · Quantity · Max >1 · Optional

   To specify quantity information.

   The QTY segment is used to record the total number of subscribers and dependents in the transaction set.

7. N1 Loop Mandatory Repeat 10

   1. 070 · N1 · Name · Max 1 · Mandatory

      To identify a party by type of organization, name and code

      At least one iteration of the N1 loop is required to identify the sender or receiver.

   2. 080 · N2 · Additional Name Information · Max 2 · Optional

      To specify additional names or those longer than 35 characters in length

   3. 090 · N3 · Address Information · Max 2 · Optional

      To specify the location of the named party

   4. 100 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 110 · PER · Administrative Communications Contact · Max 3 · Optional

      To identify a person or office to whom administrative communications should be directed

   6. ACT Loop Optional Repeat 2

      1. 120 · ACT · Account Identification · Max 1 · Mandatory

         To specify account information.

      2. 130 · REF · Reference Numbers · Max 5 · Optional

         To specify identifying numbers.

      3. 140 · N3 · Address Information · Max 1 · Optional

         To specify the location of the named party

      4. 150 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      5. 160 · PER · Administrative Communications Contact · Max 5 · Optional

         To identify a person or office to whom administrative communications should be directed

      6. 170 · DTP · Date or Time or Period · Max 1 · Optional

         To specify any or all of a date, a time, or a time period

      7. 180 · AMT · Monetary Amount · Max 1 · Optional

         To indicate the total monetary amount.

Detail

1. INS Loop Mandatory Repeat >1

   1. 010 · INS · Insured Benefit · Max 1 · Mandatory

      To provide benefit information on insured entities

      A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information.

   2. 020 · REF · Reference Numbers · Max >1 · Mandatory

      To specify identifying numbers.

      The REF segment is required to link the dependent(s) to the subscriber.

   3. 030 · NM1 · Individual or Organizational Name · Max 2 · Optional

      To supply the full name of an individual or organizational entity

   4. 040 · DTP · Date or Time or Period · Max >1 · Optional

      To specify any or all of a date, a time, or a time period

   5. 050 · N3 · Address Information · Max 1 · Optional

      To specify the location of the named party

      The N3 and N4 segments within the INS loop are used to report the address of the subscriber or the dependent.

   6. 060 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   7. 080 · DMG · Demographic Information · Max 1 · Optional

      To supply demographic information

   8. 090 · PM · Electronic Funds Transfer Information · Max 1 · Optional

      To supply information on the electronic funds transfer (EFT) method of payment

   9. 100 · EC · Employment Class · Max 5 · Optional

      To provide class of employment information

   10. 110 · ICM · Individual Income · Max 1 · Optional

       To supply information to determine benefit eligibility, deductibles and retirement and investment contributions

   11. 120 · AMT · Monetary Amount · Max 10 · Optional

       To indicate the total monetary amount.

   12. 130 · HLH · Health Information · Max 1 · Optional

       To provide health information

   13. 140 · CD2 · Multi-Valued Characteristics · Max 10 · Optional

       To provide characteristics that may have multiple values

       The CD2 segment is used to record Pre-existing Conditions.

   14. N1 Loop Optional Repeat 2

       1. 160 · N1 · Name · Max 1 · Mandatory

          To identify a party by type of organization, name and code

          The N1 loop may only appear for a Dependent to report school and or employment information.

       2. 170 · DTP · Date or Time or Period · Max 1 · Optional

          To specify any or all of a date, a time, or a time period

       3. 180 · N3 · Address Information · Max 1 · Optional

          To specify the location of the named party

          The N3 and N4 segments are used to report the address of the school or the employer.

       4. 190 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

   15. DSB Loop Optional Repeat 4

       1. 200 · DSB · Disability Information · Max 1 · Mandatory

          To supply disability information

          The DSB loop may only appear for the Subscriber.

       2. 210 · DTP · Date or Time or Period · Max 10 · Optional

          To specify any or all of a date, a time, or a time period

       3. 220 · AD1 · Adjustment Amount · Max 10 · Optional

          To specify the characteristics of an adjustment

   16. PER Loop Optional Repeat 10

       1. 230 · PER · Administrative Communications Contact · Max 1 · Mandatory

          To identify a person or office to whom administrative communications should be directed

       2. 240 · N3 · Address Information · Max 1 · Optional

          To specify the location of the named party

          The N3 and N4 segments are used to report the address of the responsible person and or the emergency contact.

       3. 250 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

   17. HD Loop Optional Repeat 99

       1. 260 · HD · Health Coverage · Max 1 · Mandatory

          To provide information on health coverage

       2. 270 · DTP · Date or Time or Period · Max 10 · Optional

          To specify any or all of a date, a time, or a time period

       3. 280 · AMT · Monetary Amount · Max 3 · Optional

          To indicate the total monetary amount.

       4. 290 · REF · Reference Numbers · Max 5 · Optional

          To specify identifying numbers.

       5. 300 · IDC · Identification Card · Max 2 · Optional

          To provide notification to produce replacement identification card

       6. LX Loop Optional Repeat 30

          1. 310 · LX · Assigned Number · Max 1 · Mandatory

             To reference a line number in a transaction set.

             The LX loop contains information about the primary care providers for the subscriber or the dependent, and about the beneficiaries of any employer-sponsored life insurance for the subscriber.

          2. 320 · NM1 · Individual or Organizational Name · Max 1 · Optional

             To supply the full name of an individual or organizational entity

             Either NM1 or N1 will be included depending on whether an individual or organization is being specified.

          3. 330 · N1 · Name · Max 2 · Optional

             To identify a party by type of organization, name and code

          4. 340 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          5. 350 · N3 · Address Information · Max 2 · Optional

             To specify the location of the named party

          6. 360 · N4 · Geographic Location · Max 2 · Optional

             To specify the geographic place of the named party

          7. 370 · PER · Administrative Communications Contact · Max 2 · Optional

             To identify a person or office to whom administrative communications should be directed

          8. 380 · PRV · Provider Information · Max 1 · Optional

             To specify the identifying characteristics of a provider

          9. 390 · DTP · Date or Time or Period · Max 6 · Optional

             To specify any or all of a date, a time, or a time period

       7. COB Loop Optional Repeat 5

          1. 400 · COB · Coordination of Benefits · Max 1 · Mandatory

             To supply information on coordination of benefits

          2. 410 · N1 · Name · Max 1 · Optional

             To identify a party by type of organization, name and code

          3. 420 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          4. 430 · N3 · Address Information · Max 2 · Optional

             To specify the location of the named party

          5. 440 · N4 · Geographic Location · Max 1 · Optional

             To specify the geographic place of the named party

          6. 450 · DTP · Date or Time or Period · Max 2 · Optional

             To specify any or all of a date, a time, or a time period

   18. LC Loop Optional Repeat 10

       1. 460 · LC · Life Coverage · Max 1 · Mandatory

          To provide information on life coverage

       2. 470 · AMT · Monetary Amount · Max 5 · Optional

          To indicate the total monetary amount.

       3. 480 · DTP · Date or Time or Period · Max 2 · Optional

          To specify any or all of a date, a time, or a time period

       4. BEN Loop Optional Repeat 20

          1. 490 · BEN · Beneficiary or Owner Information · Max 1 · Mandatory

             To supply beneficiary, co-participant, and owner information

          2. 500 · NM1 · Individual or Organizational Name · Max 1 · Optional

             To supply the full name of an individual or organizational entity

          3. 510 · N1 · Name · Max 1 · Optional

             To identify a party by type of organization, name and code

          4. 520 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          5. 530 · N3 · Address Information · Max 1 · Optional

             To specify the location of the named party

          6. 540 · N4 · Geographic Location · Max 1 · Optional

             To specify the geographic place of the named party

          7. 542 · DMG · Demographic Information · Max 1 · Optional

             To supply demographic information

   19. FSA Loop Optional Repeat 5

       1. 550 · FSA · Flexible Spending Account · Max 1 · Mandatory

          To supply flexible spending account information

          The FSA loop may only appear for the Subscriber.

       2. 560 · AMT · Monetary Amount · Max 10 · Optional

          To indicate the total monetary amount.

       3. 570 · DTP · Date or Time or Period · Max 10 · Optional

          To specify any or all of a date, a time, or a time period

   20. RP Loop Optional Repeat >1

       1. 580 · RP · Retirement Product · Max 1 · Mandatory

          To specify the retirement product characteristics

       2. 590 · DTP · Date or Time or Period · Max >1 · Optional

          To specify any or all of a date, a time, or a time period

       3. 592 · REF · Reference Numbers · Max >1 · Optional

          To specify identifying numbers.

       4. 594 · INV · Investment Vehicle Selection · Max >1 · Optional

          To specify type of investment vehicle or account and other basic data about the investment

       5. 596 · AMT · Monetary Amount · Max 20 · Optional

          To indicate the total monetary amount.

       6. 597 · QTY · Quantity · Max 20 · Optional

          To specify quantity information.

       7. 598 · K3 · File Information · Max 3 · Optional

          To transmit a fixed format record

       8. NM1 Loop Optional Repeat >1

          1. 610 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

             To supply the full name of an individual or organizational entity

          2. 630 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names or those longer than 35 characters in length

          3. 651 · DMG · Demographic Information · Max 1 · Optional

             To supply demographic information

          4. 652 · BEN · Beneficiary or Owner Information · Max 1 · Optional

             To supply beneficiary, co-participant, and owner information

          5. 653 · REF · Reference Numbers · Max >1 · Optional

             To specify identifying numbers.

          6. NX1 Loop Optional Repeat >1

             1. 654 · NX1 · Property or Entity Identification · Max 1 · Mandatory

                To define the attributes of a property or an entity

             2. 655 · N3 · Address Information · Max 1 · Optional

                To specify the location of the named party

             3. 656 · N4 · Geographic Location · Max 1 · Optional

                To specify the geographic place of the named party

             4. 657 · DTP · Date or Time or Period · Max >1 · Optional

                To specify any or all of a date, a time, or a time period

       9. FC Loop Optional Repeat >1

          1. 660 · FC · Financial Contribution · Max 1 · Mandatory

             To specify the financial contribution information

          2. 670 · DTP · Date or Time or Period · Max >1 · Optional

             To specify any or all of a date, a time, or a time period

          3. INV Loop Optional Repeat >1

             1. 678 · INV · Investment Vehicle Selection · Max 1 · Mandatory

                To specify type of investment vehicle or account and other basic data about the investment

             2. 679 · DTP · Date or Time or Period · Max >1 · Optional

                To specify any or all of a date, a time, or a time period

             3. 680 · QTY · Quantity · Max >1 · Optional

                To specify quantity information.

             4. 681 · ENT · Entity · Max >1 · Optional

                To designate the entities which are parties to a transaction and specify a reference meaningful to those entities

             5. 682 · REF · Reference Numbers · Max >1 · Optional

                To specify identifying numbers.

             6. 683 · AMT · Monetary Amount · Max 20 · Optional

                To indicate the total monetary amount.

             7. 684 · K3 · File Information · Max 3 · Optional

                To transmit a fixed format record

       10. AIN Loop Optional Repeat >1

           1. 685 · AIN · Income · Max 1 · Mandatory

              To provide type and amount of income obtained

           2. 686 · QTY · Quantity · Max >1 · Optional

              To specify quantity information.

           3. 687 · DTP · Date or Time or Period · Max >1 · Optional

              To specify any or all of a date, a time, or a time period

2. 690 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments).