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
- 010Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 020Beginning SegmentMandatoryMax 1
To indicate the beginning of a transaction set.
- 030Reference NumbersMandatoryMax >1
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. - 040Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 050Monetary AmountOptionalMax >1
To indicate the total monetary amount.
The AMT segment is used to record the total Flexible Spending Account contributions in the transaction set. - 060QuantityOptionalMax >1
To specify quantity information.
The QTY segment is used to record the total number of subscribers and dependents in the transaction set. - N1 Loop MandatoryRepeat 10
- 070NameMandatoryMax 1
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. - 080Additional Name InformationOptionalMax 2
To specify additional names or those longer than 35 characters in length
- 090Address InformationOptionalMax 2
To specify the location of the named party
- 100Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 110Administrative Communications ContactOptionalMax 3
To identify a person or office to whom administrative communications should be directed
- ACT Loop OptionalRepeat 2
- 120Account IdentificationMandatoryMax 1
To specify account information.
- 130Reference NumbersOptionalMax 5
To specify identifying numbers.
- 140Address InformationOptionalMax 1
To specify the location of the named party
- 150Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 160Administrative Communications ContactOptionalMax 5
To identify a person or office to whom administrative communications should be directed
- 170Date or Time or PeriodOptionalMax 1
To specify any or all of a date, a time, or a time period
- 180Monetary AmountOptionalMax 1
To indicate the total monetary amount.
- 120Account IdentificationMandatoryMax 1
- 070NameMandatoryMax 1
Detail
- INS Loop MandatoryRepeat >1
- 010Insured BenefitMandatoryMax 1
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. - 020Reference NumbersMandatoryMax >1
To specify identifying numbers.
The REF segment is required to link the dependent(s) to the subscriber. - 030Individual or Organizational NameOptionalMax 2
To supply the full name of an individual or organizational entity
- 040Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 050Address InformationOptionalMax 2
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. - 060Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 080Demographic InformationOptionalMax 1
To supply demographic information
- 090Electronic Funds Transfer InformationOptionalMax 1
To supply information on the electronic funds transfer (EFT) method of payment
- 100Employment ClassOptionalMax 5
To provide class of employment information
- 110Individual IncomeOptionalMax 1
To supply information to determine benefit eligibility, deductibles and retirement and investment contributions
- 120Monetary AmountOptionalMax 10
To indicate the total monetary amount.
- 130Health InformationOptionalMax 1
To provide health information
- 140Multi-Valued CharacteristicsOptionalMax 10
To provide characteristics that may have multiple values
The CD2 segment is used to record Pre-existing Conditions. - N1 Loop OptionalRepeat 2
- 160NameMandatoryMax 1
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. - 170Date or Time or PeriodOptionalMax 1
To specify any or all of a date, a time, or a time period
- 180Address InformationOptionalMax 1
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. - 190Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 160NameMandatoryMax 1
- DSB Loop OptionalRepeat 4
- 200Disability InformationMandatoryMax 1
To supply disability information
The DSB loop may only appear for the Subscriber. - 210Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 220Adjustment AmountOptionalMax 10
To specify the characteristics of an adjustment
- 200Disability InformationMandatoryMax 1
- PER Loop OptionalRepeat 10
- 230Administrative Communications ContactMandatoryMax 1
To identify a person or office to whom administrative communications should be directed
- 240Address InformationOptionalMax 1
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. - 250Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 230Administrative Communications ContactMandatoryMax 1
- HD Loop OptionalRepeat 99
- 260Health CoverageMandatoryMax 1
To provide information on health coverage
- 270Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 280Monetary AmountOptionalMax 3
To indicate the total monetary amount.
- 290Reference NumbersOptionalMax 5
To specify identifying numbers.
- 300Identification CardOptionalMax >1
To provide notification to produce replacement identification card
- LX Loop OptionalRepeat 30
- 310Assigned NumberMandatoryMax 1
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. - 320Individual or Organizational NameOptionalMax 1
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. - 330NameOptionalMax 3
To identify a party by type of organization, name and code
- 340Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 350Address InformationOptionalMax 2
To specify the location of the named party
- 360Geographic LocationOptionalMax 2
To specify the geographic place of the named party
- 370Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 380Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 390Date or Time or PeriodOptionalMax 6
To specify any or all of a date, a time, or a time period
- 310Assigned NumberMandatoryMax 1
- COB Loop OptionalRepeat 5
- 400Coordination of BenefitsMandatoryMax 1
To supply information on coordination of benefits
- 410NameOptionalMax 1
To identify a party by type of organization, name and code
- 420Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 430Address InformationOptionalMax 2
To specify the location of the named party
- 440Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 450Date or Time or PeriodOptionalMax 2
To specify any or all of a date, a time, or a time period
- 400Coordination of BenefitsMandatoryMax 1
- 260Health CoverageMandatoryMax 1
- LC Loop OptionalRepeat 10
- 460Life CoverageMandatoryMax 1
To provide information on life coverage
- 470Monetary AmountOptionalMax 5
To indicate the total monetary amount.
- 480Date or Time or PeriodOptionalMax 2
To specify any or all of a date, a time, or a time period
- BEN Loop OptionalRepeat 20
- 490Beneficiary or Owner InformationMandatoryMax 1
To supply beneficiary, co-participant, and owner information
- 500Individual or Organizational NameOptionalMax 1
To supply the full name of an individual or organizational entity
- 510NameOptionalMax 1
To identify a party by type of organization, name and code
- 520Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 530Address InformationOptionalMax 1
To specify the location of the named party
- 540Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 542Demographic InformationOptionalMax 1
To supply demographic information
- 490Beneficiary or Owner InformationMandatoryMax 1
- 460Life CoverageMandatoryMax 1
- FSA Loop OptionalRepeat 5
- 550Flexible Spending AccountMandatoryMax 1
To supply flexible spending account information
The FSA loop may only appear for the Subscriber. - 560Monetary AmountOptionalMax 10
To indicate the total monetary amount.
- 570Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 550Flexible Spending AccountMandatoryMax 1
- RP Loop OptionalRepeat >1
- 580Retirement ProductMandatoryMax 1
To specify the retirement product characteristics
- 590Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 592Reference NumbersOptionalMax >1
To specify identifying numbers.
- 594Investment Vehicle SelectionOptionalMax >1
To specify type of investment vehicle or account and other basic data about the investment
- 596Monetary AmountOptionalMax 20
To indicate the total monetary amount.
- 597QuantityOptionalMax 20
To specify quantity information.
- 598File InformationOptionalMax 3
To transmit a fixed format record
- NM1 Loop OptionalRepeat >1
- 610Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 630Additional Name InformationOptionalMax 1
To specify additional names or those longer than 35 characters in length
- 651Demographic InformationOptionalMax 1
To supply demographic information
- 652Beneficiary or Owner InformationOptionalMax 1
To supply beneficiary, co-participant, and owner information
- 653Reference NumbersOptionalMax >1
To specify identifying numbers.
- NX1 Loop OptionalRepeat >1
- 654Property or Entity IdentificationMandatoryMax 1
To define the attributes of a property or an entity
- 655Address InformationOptionalMax 1
To specify the location of the named party
- 656Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 657Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 654Property or Entity IdentificationMandatoryMax 1
- 610Individual or Organizational NameMandatoryMax 1
- FC Loop OptionalRepeat >1
- 660Financial ContributionMandatoryMax 1
To specify the financial contribution information
- 670Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- INV Loop OptionalRepeat >1
- 678Investment Vehicle SelectionMandatoryMax 1
To specify type of investment vehicle or account and other basic data about the investment
- 679Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 680QuantityOptionalMax >1
To specify quantity information.
- 681EntityOptionalMax >1
To designate the entities which are parties to a transaction and specify a reference meaningful to those entities
- 682Reference NumbersOptionalMax >1
To specify identifying numbers.
- 683Monetary AmountOptionalMax 20
To indicate the total monetary amount.
- 684File InformationOptionalMax 3
To transmit a fixed format record
- 678Investment Vehicle SelectionMandatoryMax 1
- 660Financial ContributionMandatoryMax 1
- AIN Loop OptionalRepeat >1
- 685IncomeMandatoryMax 1
To provide type and amount of income obtained
- 686QuantityOptionalMax >1
To specify quantity information.
- 687Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 685IncomeMandatoryMax 1
- 580Retirement ProductMandatoryMax 1
- 010Insured BenefitMandatoryMax 1
- 690Transaction 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).