834

Benefit Enrollment and Maintenance

Functional Group=BE

This Draft Standard for Trial Use 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.

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

 

ISA

Interchange Control Header

M

1

 

 

Required

     

 

 

GS

Functional Group Header

M

1

 

 

Required

     

Heading:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

010

ST

Transaction Set Header

M

1

 

 

Required

     

 

020

BGN

Beginning Segment

M

1

 

 

Required

     

 

030

REF

Transaction Set Policy Number

O

1

 

 

Situational

     

 

040

DTP

File Effective Date

O

>1

 

 

Situational

     

LOOP ID - 1000A

 

 

1

N1/070L

 

 

 

 

 

070

N1

Sponsor Name

M

1

 

 

Required

     

LOOP ID - 1000B

 

 

1

N1/070L

 

 

 

 

 

070

N1

Payer

M

1

 

 

Required

     

LOOP ID - 1000C

 

 

2

N1/070L

 

 

 

 

 

070

N1

TPA/Broker Name

O

1

 

 

Situational

     

LOOP ID - 1100C

 

 

1

 

 

 

 

 

 

120

ACT

TPA/Broker Account Information

O

1

 

 

Situational

     

Detail:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

LOOP ID - 2000

 

 

>1

 

 

 

 

 

 

010

INS

Member Level Detail

O

1

 

N2/010

Required

     

 

020

REF

Subscriber Number

M

1

 

N2/020

Required

     

 

020

REF

Member Policy Number

O

1

 

N2/020

Situational

     

 

020

REF

Member Identification Number

O

5

 

N2/020

Situational

     

 

020

REF

Prior Coverage Months

O

1

 

N2/020

Situational

     

 

025

DTP

Member Level Dates

O

20

 

 

Situational

     

LOOP ID - 2100A

 

 

1

 

 

 

 

 

 

030

NM1

Member Name

O

1

 

 

Required

     

 

040

PER

Member Communications Numbers

O

1

 

 

Situational

     

 

050

N3

Member Residence Street Address

O

1

 

 

Situational

     

 

060

N4

Member Residence City, State, ZIP Code

O

1

 

 

Situational

     

 

080

DMG

Member Demographics

O

1

 

 

Situational

     

 

110

ICM

Member Income

O

1

 

 

Situational

     

 

120

AMT

Member Policy Amounts

O

4

 

 

Situational

     

 

130

HLH

Member Health Information

O

1

 

 

Situational

     

 

150

LUI

Member Language

O

5

 

 

Situational

     

LOOP ID - 2100B

 

 

1

 

 

 

 

 

 

030

NM1

Incorrect Member Name

O

1

 

 

Situational

     

 

080

DMG

Incorrect Member Demographics

O

1

 

 

Situational

     

LOOP ID - 2100C

 

 

1

 

 

 

 

 

 

030

NM1

Member Mailing Address

O

1

 

 

Situational

     

 

050

N3

Member Mail Street Address

O

1

 

 

Situational

     

 

060

N4

Member Mail City, State, Zip

O

1

 

 

Situational

     

LOOP ID - 2100D

 

 

3

 

 

 

 

 

 

030

NM1

Member Employer

O

1

 

 

Situational

     

 

040

PER

Member Employer Communications Numbers

O

1

 

 

Situational

     

 

050

N3

Member Employer Street Address

O

1

 

 

Situational

     

 

060

N4

Member Employer City, State, Zip

O

1

 

 

Situational

     

LOOP ID - 2100E

 

 

3

 

 

 

 

 

 

030

NM1

Member School

O

1

 

 

Situational

     

 

040

PER

Member School Commmunications Numbers

O

1

 

 

Situational

     

 

050

N3

Member School Street Address

O

1

 

 

Situational

     

 

060

N4

Member School City, State, Zip

O

1

 

 

Situational

     

LOOP ID - 2100F

 

 

1

 

 

 

 

 

 

030

NM1

Custodial Parent

O

1

 

 

Situational

     

 

040

PER

Custodial Parent Communications Numbers

O

1

 

 

Situational

     

 

050

N3

Custodial Parent Street Address

O

1

 

 

Situational

     

 

060

N4

Custodial Parent City, State, Zip

O

1

 

 

Situational

     

LOOP ID - 2100G

 

 

1

 

 

 

 

 

 

030

NM1

Responsible Person

O

1

 

 

Situational

     

 

040

PER

Responsible Person Communications Numbers

O

1

 

 

Situational

     

 

050

N3

Responsible Person Street Address

O

1

 

 

Situational

     

 

060

N4

Responsible Person City, State, Zip

O

1

 

 

Situational

     

LOOP ID - 2200

 

 

1

N2/200L

 

 

 

 

 

200

DSB

Disability Information

O

1

 

 

Situational

     

 

210

DTP

Disability Eligibility Dates

O

2

 

 

Situational

     

LOOP ID - 2300

 

 

99

 

 

 

 

 

 

260

HD

Health Coverage

O

1

 

 

Situational

     

 

270

DTP

Health Coverage Dates

O

4

 

 

Required

     

 

280

AMT

Health Coverage Policy

O

4

 

 

Situational

     

 

290

REF

Health Coverage Policy Number

O

2

 

 

Situational

     

 

300

IDC

Identification Card

O

10

 

 

Situational

     

LOOP ID - 2310

 

 

30

N2/310L

 

 

 

 

 

310

LX

Provider Information

O

1

 

 

Situational

     

 

320

NM1

Provider Name

O

1

 

N2/320

Required

     

 

360

N4

Provider City, State, ZIP Code

O

1

 

 

Situational

     

 

370

PER

Provider Communications Numbers

O

2

 

 

Situational

     

 

395

PLA

PCP Change Reason

O

1

 

 

Situational

     

LOOP ID - 2320

 

 

5

 

 

 

 

 

 

400

COB

Coordination of Benefits

O

1

 

 

Situational

     

 

405

REF

Additional Coordination of Benefits Identifiers

O

5

 

 

Situational

     

 

410

N1

Other Insurance Company Name

O

1

 

 

Situational

     

 

450

DTP

Coordination of Benefits Eligibility Dates

O

2

 

 

Situational

     

 

690

SE

Transaction Set Trailer

M

1

 

 

Required

     

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

 

GE

Functional Group Trailer

M

1

 

 

Required

     

 

 

IEA

Interchange Control Trailer

M

1

 

 

Required

     

Notes:

1/070L

At least one iteration of loop 1000 is required to identify the sender or receiver.

1/070L

At least one iteration of loop 1000 is required to identify the sender or receiver.

1/070L

At least one iteration of loop 1000 is required to identify the sender or receiver.

2/010

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

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

2/020

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

2/020

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

2/020

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

2/200L

The DSB loop may only appear for the Subscriber.

2/310L

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.

2/320

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


Next