EDI 834 Benefit Enrollment And Maintenance

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.

Segments

Position
Segment
Name
Max use
100
ST
Transaction Set Header
Mandatory
AtMax 1
To indicate the start of a transaction set and to assign a control number
200
BGN
Beginning Segment
Mandatory
AtMax 1
To indicate the beginning of a transaction set
300
REF
Reference Information
Opt
GT 1
To specify identifying information
400
DTP
Date or Time or Period
Opt
GT 1
To specify any or all of a date, a time, or a time period
500
AMT
Monetary Amount Information
Opt
GT 1
To indicate the total monetary amount
600
QTY
Quantity Information
Opt
GT 1
To specify quantity information
1000
LOOP
Mandatory
GT 1
2000
LOOP
Opt
GT 1
2200
LOOP
Opt
AtMax 4
2300
LOOP
Opt
AtMax 99
2320
LOOP
Opt
AtMax 10
2400
LOOP
Opt
AtMax 10
2500
LOOP
Opt
AtMax 10
2600
LOOP
Opt
GT 1
2630
LOOP
Opt
GT 1
2650
LOOP
Opt
GT 1
6880
LS
Loop Header
Opt
AtMax 1
To indicate that the next segment begins a loop
2700
LOOP
Opt
GT 1
6885
LE
Loop Trailer
Opt
AtMax 1
To indicate that the loop immediately preceding this segment is complete
6900
SE
Transaction Set Trailer
Mandatory
AtMax 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)

Elements

PositionElementNameRequirementTypeMin/MaxRepeat
1
143
Transaction Set Identifier CodeMandatoryID3/31
2
329
Transaction Set Control NumberMandatoryAlphanumeric4/91
3
1705
Implementation Convention ReferenceOptAlphanumeric1/351