834

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Updated:05/16/2008

HIPAA 834 Benefit Enrollment & Maintenance
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

Notes: In order to protect the security and confidentiality of electronic health information, Congress has passed The Health Insurance Portability and Accountability Act, also known as HIPAA, which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.

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.

Heading:
Pos Id Segment Name Req Max Use Repeat Notes Usage
010 ST Transaction Set Header M 1
020 BGN Beginning Segment M 1
030 REF Transaction Set Policy Number O 1
040 DTP File Effective Date O >1
Loop ID - 1000A 1
070 N1 Sponsor Name M 1 N1/070
Loop ID - 1000B 1
070 N1 Payer M 1 N1/070
Loop ID - 1000C 2
070 N1 TPA/Broker Name O 1 N1/070
Loop ID - 1100C 1
120 ACT TPA/Broker Account Information O 1
Detail:
Pos Id Segment Name Req Max Use Repeat Notes Usage
Loop ID - 2000 >1
010 INS Member Level Detail O 1 N2/010
020 REF Subscriber Number M 1 N2/020
020 REF Member Policy Number O 1 N2/020
020 REF Member Identification Number O 5 N2/020
020 REF Prior Coverage Months O 1 N2/020
025 DTP Member Level Dates O 20
Loop ID - 2100A 1
030 NM1 Member Name O 1
040 PER Member Communications Numbers O 1
050 N3 Member Residence Street Address O 1
060 N4 Member Residence City, State, ZIP Code O 1
080 DMG Member Demographics O 1
110 ICM Member Income O 1
120 AMT Member Policy Amounts O 4
130 HLH Member Health Information O 1
150 LUI Member Language O 5
Loop ID - 2100B 1
030 NM1 Incorrect Member Name O 1
080 DMG Incorrect Member Demographics O 1
Loop ID - 2100C 1
030 NM1 Member Mailing Address O 1
050 N3 Member Mail Street Address O 1
060 N4 Member Mail City, State, Zip O 1
Loop ID - 2100D 3
030 NM1 Member Employer O 1
040 PER Member Employer Communications Numbers O 1
050 N3 Member Employer Street Address O 1
060 N4 Member Employer City, State, Zip O 1
Loop ID - 2100E 3
030 NM1 Member School O 1
040 PER Member School Commmunications Numbers O 1
050 N3 Member School Street Address O 1
060 N4 Member School City, State, Zip O 1
Loop ID - 2100F 1
030 NM1 Custodial Parent O 1
040 PER Custodial Parent Communications Numbers O 1
050 N3 Custodial Parent Street Address O 1
060 N4 Custodial Parent City, State, Zip O 1
Loop ID - 2100G 1
030 NM1 Responsible Person O 1
040 PER Responsible Person Communications Numbers O 1
050 N3 Responsible Person Street Address O 1
060 N4 Responsible Person City, State, Zip O 1
Loop ID - 2200 1
200 DSB Disability Information O 1 N2/200
210 DTP Disability Eligibility Dates O 2
Loop ID - 2300 99
260 HD Health Coverage O 1
270 DTP Health Coverage Dates O 4
280 AMT Health Coverage Policy O 4
290 REF Health Coverage Policy Number O 2
300 IDC Identification Card O 10
Loop ID - 2310 30
310 LX Provider Information O 1 N2/310
320 NM1 Provider Name O 1 N2/320
360 N4 Provider City, State, ZIP Code O 1
370 PER Provider Communications Numbers O 2
395 PLA PCP Change Reason O 1
Loop ID - 2320 5
400 COB Coordination of Benefits O 1
405 REF Additional Coordination of Benefits Identifiers O 5
410 N1 Other Insurance Company Name O 1
450 DTP Coordination of Benefits Eligibility Dates O 2
690 SE Transaction Set Trailer M 1

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