EDI 834 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
- 0300Reference InformationOptionalMax >1
To specify identifying information
- 0400Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 0500Monetary Amount InformationOptionalMax >1
To indicate the total monetary amount
The AMT segment is used to record the total Flexible Spending Account contributions in the transaction set. - 0600Quantity InformationOptionalMax >1
To specify quantity information
The QTY segment is used to record the total number of subscribers and dependents in the transaction set. - 1000 Loop MandatoryRepeat >1
- 0700Party IdentificationMandatoryMax 1
To identify a party by type of organization, name, and code
At least one iteration of loop 1000 is required to identify the sender or receiver. - 0800Additional Name InformationOptionalMax 2
To specify additional names
- 0900Party LocationOptionalMax 2
To specify the location of the named party
- 1000Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 1100Administrative Communications ContactOptionalMax 3
To identify a person or office to whom administrative communications should be directed
- 1100 Loop OptionalRepeat 10
- 1200Account IdentificationMandatoryMax 1
To specify account information
- 1300Reference InformationOptionalMax 5
To specify identifying information
- 1400Party LocationOptionalMax 1
To specify the location of the named party
- 1500Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 1600Administrative Communications ContactOptionalMax 5
To identify a person or office to whom administrative communications should be directed
- 1700Date or Time or PeriodOptionalMax 1
To specify any or all of a date, a time, or a time period
- 1800Monetary Amount InformationOptionalMax 1
To indicate the total monetary amount
- 1200Account IdentificationMandatoryMax 1
- 0700Party IdentificationMandatoryMax 1
Detail
- 2000 Loop OptionalRepeat >1
- 0100Insured BenefitMandatoryMax 1
To provide benefit, characteristics, and identification 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. - 0200Reference InformationMandatoryMax >1
To specify identifying information
The REF segment is required to link the dependent(s) to the subscriber. - 0250Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 2100 Loop OptionalRepeat >1
- 0300Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 0400Administrative Communications ContactOptionalMax 5
To identify a person or office to whom administrative communications should be directed
- 0500Party LocationOptionalMax 1
To specify the location of the named party
- 0600Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 0800Demographic InformationOptionalMax 1
To supply demographic information
- 0900Electronic Funds Transfer InformationOptionalMax 1
To supply information on the electronic funds transfer (EFT) method of payment
- 1000Employment ClassOptionalMax >1
To provide class of employment information
- 1100Individual IncomeOptionalMax 1
To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions
- 1200Monetary Amount InformationOptionalMax 10
To indicate the total monetary amount
- 1300Health InformationOptionalMax 1
To provide health information
- 1400Health Care Information CodesOptionalMax 10
To supply information related to the delivery of health care
- 1500Language UseOptionalMax >1
To specify language, type of usage, and proficiency or fluency
- 0300Individual or Organizational NameMandatoryMax 1
- 2200 Loop OptionalRepeat 4
- 2000Disability InformationMandatoryMax 1
To supply disability information
- 2100Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 2200Adjustment AmountOptionalMax 10
To specify the characteristics of an adjustment
- 2000Disability InformationMandatoryMax 1
- 2300 Loop OptionalRepeat 99
- 2600Health CoverageMandatoryMax 1
To provide information on health coverage
- 2700Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 2800Monetary Amount InformationOptionalMax >1
To indicate the total monetary amount
- 2900Reference InformationOptionalMax >1
To specify identifying information
- 3000Identification CardOptionalMax >1
To provide notification to produce replacement identification card(s)
- 2310 Loop OptionalRepeat 30
- 3100Transaction Set Line NumberMandatoryMax 1
To reference a line number in a transaction set
Loop 2310 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. - 3200Individual 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. - 3300Party IdentificationOptionalMax 3
To identify a party by type of organization, name, and code
- 3400Additional Name InformationOptionalMax 1
To specify additional names
- 3500Party LocationOptionalMax 2
To specify the location of the named party
- 3600Geographic LocationOptionalMax 2
To specify the geographic place of the named party
- 3700Administrative Communications ContactOptionalMax 2
To identify a person or office to whom administrative communications should be directed
- 3800Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
- 3900Date or Time or PeriodOptionalMax 6
To specify any or all of a date, a time, or a time period
- 3950Place or LocationOptionalMax 1
To indicate action to be taken for the location specified and to qualify the location specified
- 3100Transaction Set Line NumberMandatoryMax 1
- 2320 Loop OptionalRepeat 10
- 4000Coordination of BenefitsMandatoryMax 1
To supply information on coordination of benefits
- 4050Reference InformationOptionalMax >1
To specify identifying information
- 4070Date or Time or PeriodOptionalMax 2
To specify any or all of a date, a time, or a time period
- 2330 Loop OptionalRepeat 3
- 4100Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 4200Additional Name InformationOptionalMax 1
To specify additional names
- 4300Party LocationOptionalMax 2
To specify the location of the named party
- 4400Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 4500Administrative Communications ContactOptionalMax 1
To identify a person or office to whom administrative communications should be directed
- 4100Individual or Organizational NameMandatoryMax 1
- 4000Coordination of BenefitsMandatoryMax 1
- 2600Health CoverageMandatoryMax 1
- 2400 Loop OptionalRepeat 10
- 4600Life CoverageMandatoryMax 1
To provide information on life coverage
- 4700Monetary Amount InformationOptionalMax 5
To indicate the total monetary amount
- 4800Date or Time or PeriodOptionalMax 2
To specify any or all of a date, a time, or a time period
- 4850Reference InformationOptionalMax >1
To specify identifying information
- 2410 Loop OptionalRepeat 20
- 4900Beneficiary or Owner InformationMandatoryMax 1
To supply beneficiary, co-participant, and owner information
- 5000Individual or Organizational NameOptionalMax 1
To supply the full name of an individual or organizational entity
- 5100Party IdentificationOptionalMax 1
To identify a party by type of organization, name, and code
- 5200Additional Name InformationOptionalMax 1
To specify additional names
- 5300Party LocationOptionalMax 1
To specify the location of the named party
- 5400Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 5420Demographic InformationOptionalMax 1
To supply demographic information
- 4900Beneficiary or Owner InformationMandatoryMax 1
- 4600Life CoverageMandatoryMax 1
- 2500 Loop OptionalRepeat 10
- 5500Tax Advantage AccountMandatoryMax 1
To report Health Insurance Tax Advantage Account information
Loop 2500 may only appear for the Subscriber. - 5600Monetary Amount InformationOptionalMax 10
To indicate the total monetary amount
- 5700Date or Time or PeriodOptionalMax 10
To specify any or all of a date, a time, or a time period
- 5750Reference InformationOptionalMax >1
To specify identifying information
- 5500Tax Advantage AccountMandatoryMax 1
- 2600 Loop OptionalRepeat >1
- 5800Retirement ProductMandatoryMax 1
To specify the retirement product characteristics
- 5900Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 5920Reference InformationOptionalMax >1
To specify identifying information
- 5940Investment Vehicle SelectionOptionalMax >1
To specify type of investment vehicle or account and other basic data about the investment
- 5960Monetary Amount InformationOptionalMax 20
To indicate the total monetary amount
- 5970Quantity InformationOptionalMax 20
To specify quantity information
- 5980File InformationOptionalMax 3
To transmit a fixed-format record or matrix contents
- 6000RelationshipOptionalMax 1
To specify relationship and birth order of entity
- 2610 Loop OptionalRepeat >1
- 6100Individual or Organizational NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 6300Additional Name InformationOptionalMax 1
To specify additional names
- 6510Demographic InformationOptionalMax 1
To supply demographic information
- 6520Beneficiary or Owner InformationOptionalMax 1
To supply beneficiary, co-participant, and owner information
- 6530Reference InformationOptionalMax >1
To specify identifying information
- 2620 Loop OptionalRepeat >1
- 6540Property or Entity IdentificationMandatoryMax 1
To define the attributes of a property or an entity
- 6550Party LocationOptionalMax 1
To specify the location of the named party
- 6560Geographic LocationOptionalMax 1
To specify the geographic place of the named party
- 6570Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 6540Property or Entity IdentificationMandatoryMax 1
- 6100Individual or Organizational NameMandatoryMax 1
- 2630 Loop OptionalRepeat >1
- 6600Financial ContributionMandatoryMax 1
To specify the financial contribution information
- 6700Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 2640 Loop OptionalRepeat >1
- 6780Investment Vehicle SelectionMandatoryMax 1
To specify type of investment vehicle or account and other basic data about the investment
- 6790Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 6800Quantity InformationOptionalMax >1
To specify quantity information
- 6810EntityOptionalMax >1
To designate the entities which are parties to a transaction and specify a reference meaningful to those entities
- 6820Reference InformationOptionalMax >1
To specify identifying information
- 6830Monetary Amount InformationOptionalMax 20
To indicate the total monetary amount
- 6840File InformationOptionalMax 3
To transmit a fixed-format record or matrix contents
- 6780Investment Vehicle SelectionMandatoryMax 1
- 6600Financial ContributionMandatoryMax 1
- 2650 Loop OptionalRepeat >1
- 6850IncomeMandatoryMax 1
To provide type and amount of income obtained
- 6860Quantity InformationOptionalMax >1
To specify quantity information
- 6870Date or Time or PeriodOptionalMax >1
To specify any or all of a date, a time, or a time period
- 6850IncomeMandatoryMax 1
- 5800Retirement ProductMandatoryMax 1
- 6880Loop HeaderOptionalMax 1
To indicate that the next segment begins a loop
- 2700 Loop OptionalRepeat >1
- 6881Transaction Set Line NumberMandatoryMax 1
To reference a line number in a transaction set
- 2750 Loop MandatoryRepeat >1
- 6882Party IdentificationMandatoryMax 1
To identify a party by type of organization, name, and code
- 6883Reference InformationMandatoryMax 1
To specify identifying information
- 6884Date or Time or PeriodOptionalMax 1
To specify any or all of a date, a time, or a time period
- 6882Party IdentificationMandatoryMax 1
- 6881Transaction Set Line NumberMandatoryMax 1
- 6885Loop TrailerOptionalMax 1
To indicate that the loop immediately preceding this segment is complete
- 0100Insured BenefitMandatoryMax 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)