834 Benefit Enrollment and Maintenance

834 Benefit Enrollment and Maintenance HIPAA Basic Guides (Washington State Medicaid HCA)

834 Benefit Enrollment and Maintenance should be used by trading partners in conjunction with the ASC X12 TR3 834 Benefit Enrollment and Maintenance version 005010X220A1. When transmitting 834 Benefit Enrollment and Maintenance transactions, HCA follows standards developed by ASC X12. These standards involve Interchange (ISA/IEA) and Functional Group (GS/GE) Segments or “outer envelopes”. All 834 transactions are enclosed in transmission level ISA/IEA envelopes and, within transmissions, functional group level GS/GE envelopes. The segments and data elements used in outer envelopes are documented in Appendix B1 of the ASC X12 TR3 834 Implementation Guide. HCA transmits 834 Transaction files with single ISA/IEA and GS/GE envelope. 834 Transactions will have 10,000 members per ST-SE segment and may have multiple transaction sets within the same GS/GE envelope

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Health Care Authority (HCA) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses).

HCA will validate all 834 Benefit Enrollment and Maintenance transactions up to HIPAA validation levels 1 and 2. If a receiver rejects any part of a transmission, they must reject the entire transmission. Data on rejected 834 transmissions should not be used to update receiver’s databases as HCA will resend a corrected full-file replacement. HCA transmits 834 Transactions within a single functional group, even when multiple transactions (ST through SE Segments) are required.

Reporting of Dates in the 834 Dates reported on the 834 will vary based on the type of file being sent, i.e. Audit or Update. Within the Update file the dates reported will vary dependent upon the nature of the transaction, i.e. enrollment, disenrollment, change to coverage, or a demographic change that does not impact coverage.

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