EDI 834 Enrollment

EDI 834 Enrollment And Maintenance File (Caliber Health)

EDI 834 is the Benefit Enrollment transaction type found in the X12 transaction set directory. It is used by government agencies, employers, and health plans to enroll and maintain membership in a healthcare benefit plan and can be processed utilizing Healthcare EDI software. The EDI 834 spec is defined by the HIPAA X12 5010 EDI transaction type and is maintained by the TR3 schema from X12.org and published by Washington Publisher Company (WPC).

Example: EDI 834 File Layout

INS*Y*18*030*XN*A*E**FT~
REF*0F*152239999~
REF*1L*Blue~
DTP*336*D8*20070101~
NM1*IL*1*JANE*JONES****34*152239999~
N3*224 N LOS LANDINGS*7TH FLOOR~
N4*CHICAGO*IL*60661*USA~
DMG*D8*19720121*F*M~
HD*030**VIS**EMP~
DTP*348*D8*20111016~
INS*N*19*030*XN*A*E***N*N~
REF*0F*152239999~
REF*1L*Blue~
DTP*357*D8*20111015~
NM1*IL*1*JANE*BUSTER~
N3*224 N LOS LANDINGS*7TH FLOOR~
N4*CHICAGO*IL*60661*USA~
DMG*D**19911015*M-HD*030**VIS~
DTP*348*D8*20110101~
DTP*349*D8*20111015~

How is the EDI 834 used?

The EDI 834 file enumerates health plan membership enrollment statuses. These statuses includes Add, Termination, Change, and Reinstatement of benefits plan member enrollment.

  • Adds – adding new member(s) to the health plan
  • Terminations – removing an existing member(s) from the benefits plan
  • Changes – modifying a member(s) data and information for an existing benefits plan member(s)
  • Reinstatements – reinstatement of a previous benefits plan member(s)

Challenges working with EDI 834

Ensuring the EDI 834 file processing goes smoothly is very critical.  The file includes vital information that can become a major impact on the sponsor, the payer, and especially the member. Always utilize EDI Software solutions built to addresses these common healthcare data processing issues encountered by organizations processing EDI 834 files.

In the next post we will write about some EDI 834 challenges and pitfalls Caliber Health have seen over the years.

To learn more about EDI and become a certified  EDI Professional please visit our course schedule page.

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