EDI 834 Enrollment and Maintenance

EDI 834 Enrollment and Maintenance sample and explanation

The EDI 834 transaction set is used for Enrollment and Maintenance of health plan members. It contains information about the member, their enrollment details, and other relevant data. Here’s a simplified example:

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Explanation of Key Segments:

  • ISA (Interchange Control Header): This is the header segment of the interchange envelope, containing sender and receiver information, date, time, and control number.
  • GS (Functional Group Header): Groups related transaction sets.
  • ST (Transaction Set Header): Begins the transaction set.
  • BGN (Beginning Segment): Provides identifying and date information for the transaction.
  • REF (Reference Identification): Contains reference numbers.
  • DTP (Date or Time or Period): Specifies dates relevant to the transaction.
  • N1 (Name): Identifies a party by name and other attributes.
  • INS (Member Level Detail): Contains the basic member enrollment information.
  • NM1 (Individual or Organizational Name): Provides the member’s name.
  • PER (Administrative Communications Contact): Contains contact information.
  • N3 (Address Information): Provides address details.
  • N4 (Geographic Location): Provides city, state, and ZIP code.
  • DMG (Demographic Information): Contains demographic details like date of birth and gender.
  • HD (Health Coverage): Provides health coverage information.
  • SE (Transaction Set Trailer): Ends the transaction set.
  • GE (Functional Group Trailer): Ends the functional group.
  • IEA (Interchange Control Trailer): Ends the interchange envelope.

This example covers a basic enrollment scenario. Real-world EDI 834 files can be much more complex, containing many more segments and data elements based on specific business requirements and implementation guidelines.

To learn more about Healthcare EDI transactions and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.

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