An Explaination of EDI 834 File and Transaction Set

When thinking of a private health insurance exchange, you just think of a marketplace full of options. But that’s not it! There is a lot of work that goes behind the curtains, such as enrollment files, member maintenance files, plan data, billing data, and rating data. Electronic Data Interchange (EDI) is a crucial component for exchanging data for the healthcare industry as it heavily relies on EDI. Understanding how EDI 834 transactions work can help businesses streamline their operations and improve communication with their partners and clients.

Among the various EDI transaction sets, EDI 834  transactions play a crucial role in facilitating the transfer of enrollment and maintenance information. This information includes details about the payer, sponsor, and members involved in offering benefits products. From insurance agencies and government bodies to unions and employers, EDI 834 transactions are widely used in the employee benefits administration process.

In this article, we will delve into the history of EDI 834 transactions and the standard way to exchange the enrollment data via ASC and HIPAA EDI 834 – Benefit Enrollment and Maintenance File format. Whether you are a healthcare professional, a benefits administrator, or simply curious about the subject, this guide will provide valuable insights and information on EDI 834 transactions. Whether you are new to EDI or just looking to brush up on your knowledge, this article will give you the information you need to get started.

Brief History of EDI 834

EDI 834 came in 1991 with the formation of the Workgroup for Electronic Data Interchange (WEDI), a national non-profit dedicated to advancing the usage of electronic data interchange in the healthcare sector. WEDI was established in 1991 and has been instrumental in promoting and standardizing the use of EDI Services and solutions in the healthcare industry. The very next year, EDI standard sets were dictated to be adopted by the American National Standards Institute (ANSI). Most health insurance carriers follow the set format and accept the 834 formats for delivering health insurance enrollment and maintenance data.

Initially, the EDI 834 was utilized for enrolling in Medicare, but soon after, it was embraced by many different health plans and employers. The implementation of EDI 834 has made the benefits enrollment process more efficient and accurate, minimizing mistakes and simplifying administrative responsibilities.

Presently, EDI 834 remains an important aspect of the benefits enrollment process and is widely accepted by health plans, employers, and third-party administrators. The fact that it has been developed and adopted as a standard, following ANSI X12 guidelines and managed by WEDI, demonstrates the continued efforts of these organizations to advance the usage of EDI in the healthcare industry.

Defining EDI 834 -Benefit Enrollment and Maintenance

EDI 834 is a transaction set representing the Benefits Enrollment and Maintenance document. This transaction set is used by employers, government agencies, enrolling members, insurance agencies, union agencies, and others included in a healthcare benefits plan. The Health Insurance Portability and Accountability Act (HIPAA) requires that specific administrative processes, such as benefits enrollment and maintenance, must use standardized electronic transactions.

EDI 834 establishes continuous communication between the sponsor of an insurance product and the payer. To clarify, a sponsor is a party that pays for the benefits plan, and the payer (insurance company) administers the insurance product. The EDI 834 Transaction Set is an extensively utilized tool in the healthcare field, serving a critical role in the process of enrolling in benefits. It is implemented by a variety of stakeholders, each with distinct necessities and objectives. Health plans rely on the EDI 834 to manage enrollment and maintenance data for their policyholders, while employers use it to transfer benefits enrollment information for their workers to the health plans. Third-Party Administrators (TPAs) also take advantage of the EDI 834 to handle the enrollment process for several customers, including employers and health plans. Agencies such as Medicare utilize the EDI 834 to process enrollment information for those who are eligible. Furthermore, software providers that offer benefits enrollment solutions frequently use the EDI to exchange data with both health plans and employers. In essence, the EDI 834 Transaction Set is an indispensable tool that guarantees an efficient and precise benefits enrollment process in the healthcare industry.

Not to mention that the EDI 834 file format was specified by the HIPAA 5010 standard for electronic exchange. Other than new enrollments and plan subscriptions, 834 transactions may be used for –

• Changes in any member’s enrollment.
• Reinstating a member’s benefits enrollment.
• Unenrollment of any member (termination of plan membership)

What makes a Benefits Enrollment and Maintenance Document?

The EDI 834 file is organized into segments and data elements, where data elements contain a data field while the segment contains one data element.

Within a data element – you will find the date of the transaction, type of insurance plan, premium amount, as well as coverage details. However, EDI 834 offers multiple avenues for the company to use the format and include data within.

How is EDI 834 Processed and Used?

The entire process of EDI solutions starts from receiving the EDI documents into a system – be it accounting or ERP. Every trading partner using EDI has a guide manual for its implementation outlining specific segments, values accepted, applicable business rules, and data elements that are followed.

The EDI document is received by the insurance sponsor, and as soon as the document is received, an acknowledgment – 997 Functional Acknowledgement – is sent to the receiver to indicate successful accrued.

The EDI format has a standard meaning for all record types and properties, which have information classified in a way that may differ from carrier to carrier. So, a file configured by UnitedHealth can be sent to many insurance providers or carriers. The health insurance data can further be segregated into dental plans or medical plans.

Utilized EDI for healthcare includes different benefits plans and insurance types communicated, inclusive of short-term disability and long-term disability. Usually, a carrier requires different information or a modified version of an 834 file format. It is also necessary that 834 is accepted by the law.

EDI 834 Specifications and Format

The EDI 834 transaction set serves as a link between the entity that finances an insurance product and the entity responsible for paying claims and administering the coverage. The sponsor could be an employer, union, association, government agency, or other who pays for the coverage, whereas the payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), agency (Medicare, Medicaid, Champus & more) or a contracted entity who pays for the claims and administers the coverage or product or a benefit.

Delivering health insurance enrollment and maintenance data through the use of the EDI 834 format may seem simple because all health insurance carriers are required to accept this format. However, the standardization of the format only refers to the way the record types and properties are classified, not the information contained within these properties. As a result, a file that is configured for UnitedHealth cannot be used for another carrier, even if they offer the same plan. In addition, the format requirements may vary when incorporating data for other types of insurance plans, such as dental plans, and carriers often require a different format for this information.

Note: Remember that EDI 834 transactions may not take place through a third-party administrator. However, a TPA can be contracted by the sponsor to handle covered data gathering.

Below is the EDI 834 format defined and used by most EDI-managed services providers.

ISA’01*0000000000-01-0000000000*ZZ ABCDEFGHIJKLMNOʻZZ*123456789012345 101127*1719*U*00400*000003438*0*P”>

GS’PO-4405197800*999999999-20101127*1719-1421*X*00401OVICS

ST*834*0179

BGN*00*1*20050315 110650****4

REF*38 SAMPLE_POLICY_NUMBER

DTP’303 D820080321

N1 P5 COMPAN_NAME FI”000000000

INS’Y*18*030-20-A

REF’OF’SUBSCRIBER NUMBER

NM1’IL 1 JOHN DOE’R”*34*1’0000000

PER’IPHP 2138051111

N3’123 SAMPLE RD

N4’CITY’ST 12345

DMG D8 19690101 F

HD-030

DTP 348’D8’20080101

REF 1L’INDIV_POLICY_NO

SE 160179

GE 11421

IEA*1’000003438

Creating a benefits enrollment can be done manually into the standard EDI document or pulling out information from data B2B EDI integration from the in-house managed providers. With automated EDI, creating and sending the information becomes even faster. The EDI translator converts the data received into 834 documents while meeting the strict guidelines set by ANSI X12 EDI standards.

Healthcare EDI Solutions

A flexible and modern EDI supports all EDI communications methods for the payer and the receiver to seamlessly share valuable data with absolute security despite changing industry standards and trends. As EDI solutions have accelerated and been adopted, most EDI providers use advanced solutions to communicate or transmit data, like –

• Cloud based EDI
• On-premise EDI
• Hosted EDI
• Off-premise EDI
• Strategy Consultation
• HIPAA Compliance
• EDI Assessment
• Process Automation
• EDI Van Services

Components of EDI 834 transactions

The components of an EDI 834 file are critical to understanding as they determine how data is structured and transmitted between trading partners. EDI 834 files are used to exchange information related to employee benefits enrollment and maintenance. These files include several components that must be structured correctly to ensure successful data transmission.

The first component of an EDI 834 file is the loop structure. Loops are used to organize and group related data elements. The loop structure consists of repeating segments that contain the same information, such as employee data. The loop structure allows for the grouping of related information, which helps trading partners quickly identify and access the information they need. For example, in an EDI 834 file, there may be a loop structure that contains all of the data elements related to a specific employee, such as their name, address, and enrollment information. Within this loop structure, there may be several segments that contain the same types of data but with different values for each employee. Loop structures are identified within the EDI file using loop identifiers. Loop identifiers are alphanumeric codes that indicate the type of loop and the level of nesting within the file. For example, the loop identifier “HD” may be used to indicate a loop containing health coverage information, while the loop identifier “2000B” may be used to indicate a loop containing dependent information within the employee loop. By grouping related data elements together, it becomes easier to identify and access the information needed for specific purposes. Loop structures also make it possible to transmit large amounts of data in a single file, which can save time and reduce errors associated with manual data entry.

The second component of an EDI 834 file is the segment structure. Segments are individual elements of data that are used to describe a specific piece of information. For example, the N1 segment contains information about the employer, such as the employer’s name, address, and identification number. A distinct identifier is assigned to each segment, which aids in identifying the specific type of information that is included within it. EDI segment structures are standardized, with each segment having a specific format and set of rules for its use. These standards are developed and maintained by various organizations, such as the Accredited Standards Committee (ASC) X12, which is responsible for developing and maintaining the EDI X12 standard used in North America. The EDI segment structure also defines the format of the data elements contained within each segment. For example, a data element may be defined as a string of alphanumeric characters or as a specific date format. The segment structure also defines how repeating data elements are handled, such as when multiple phone numbers are associated with a single individual.

Common 834 segments include:

• INS: Insurance Information Segment
• DTP: Date or Time or Period Segment
• NM1: Individual or Organizational Name Segment
• REF: Reference Information Segment
• PER: Administrative Communications Contact Segment
• AMT: Monetary Amount Segment
• HD: Health Coverage Dates Segment

Finally, the data elements within an EDI 834 file must be organized correctly to ensure that they can be read and processed by the recipient. The file is structured according to the ANSI X12 format, which specifies how data should be formatted and arranged. The X12 format ensures that data can be transmitted between different systems and applications without errors.

Steps to set up EDI 834 transactions

Setting up EDI 834 transactions requires careful planning and coordination between trading partners. The following are the key steps involved in setting up EDI 834 transactions:

• Determine the scope of the project: Before beginning the implementation process, it is important to identify the scope of the project. This includes determining the details that will be transferred, its structure, and the trading partners involved.
• Choose an EDI software solution: An EDI software solution is necessary to translate data into the required EDI format. Select an EDI solution that is compatible with your current systems and offers the required functionality for carrying out EDI transactions.
• Establish communication protocols: Decide on the approach for exchanging EDI files with your business partners, which could include utilizing a value-added network (VAN), establishing direct EDI communication, or employing a web-based portal.
• Set up trading partner agreements: Establish trading partner agreements with your trading partners to define the terms of the EDI transactions. This includes identifying data requirements, communication protocols, and security measures.
• Map EDI data to internal systems: Map the EDI data to your internal systems to ensure that the data is processed accurately. This involves identifying the data elements in the EDI file and mapping them to the corresponding fields in your internal systems.
• Test the EDI implementation: Test the EDI implementation with your trading partners to ensure that the data is being exchanged correctly. This procedure involves swapping test files and assuring that the data is properly managed.
• Go live: Once the EDI implementation has been tested and verified, you can begin exchanging live EDI transactions with your trading partners.
• Monitor and maintain the EDI implementation: Continuously monitor and maintain the EDI implementation to ensure that it is functioning correctly. This involves tracking EDI transaction volumes, monitoring error reports, and addressing any issues that arise.

In conclusion, setting up EDI 834 transactions involves careful planning, communication, and coordination between trading partners. By following the steps outlined above, organizations can successfully implement EDI 834 transactions and streamline their benefits enrollment processes.

Tips for successful implementation

A successful implementation can include reducing manual processing time, improving accuracy, or streamlining communication with trading partners. Clear goals can help guide the implementation process and ensure that it is aligned with your organization’s strategic objectives. When selecting an EDI solution, it is important to prioritize security, scalability, and compatibility with your current systems. It may be beneficial to collaborate with a reliable EDI provider that has a history of successful implementations.

Thorough testing and validation are essential to ensure that the EDI implementation is working accurately. Planning for testing can involve exchanging test files with trading partners, conducting end-to-end testing, and verifying that data is being mapped correctly to internal systems. Another crucial factor in achieving a successful EDI implementation is establishing unambiguous communication protocols with your trading partners. This includes defining the data elements to be exchanged, communication protocols, and security measures. Clear communication protocols can ensure that everyone understands the requirements and processes involved in EDI transactions. Providing EDI implementation training to employees and trading partners is a must, so it can aid in decreasing errors and enhancing the overall efficiency of the implementation.

Monitoring and maintaining the EDI implementation is also critical to its success. This involves tracking EDI transaction volumes, monitoring error reports, and addressing any issues that arise promptly. Making continual improvements to the implementation can optimize efficiency, enhance accuracy, and decrease costs over time. This can involve analyzing transaction data to identify areas for improvement and making updates to internal systems and processes as needed.

By following these tips, organizations can successfully implement EDI transactions, including EDI 834, and realize the benefits of streamlined benefits enrollment processes, improved accuracy, and reduced manual processing time.

Benefits of EDI 834 Process

The use of the EDI process provides numerous advantages for sponsors and payers in the healthcare industry. It streamlines and automates communication between the sponsor and payer, reducing the chance of errors and accelerating data transfer. For instance, instead of manual data entry, the standardized EDI 834 file format enables smooth transmission of enrollment and maintenance information, minimizing the potential for mistakes caused by human error.

Additionally, EDI 834 processing enhances data accuracy, due to the standardization of the EDI 834 file format following strict ANSI X12 EDI guidelines. This standardization ensures consistent and precise data exchange between parties, eliminating the need for manual data entry and reducing the risk of inaccuracies.

The EDI 834 process also minimizes administrative expenses. Its automated nature eliminates the requirement for manual data entry, freeing up time and resources, resulting in reduced overhead costs, lower labor expenses, and increased efficiency. Finally, EDI 834 processing improves data security. The encrypted data transfer guarantees the protection of sensitive information and reduces the risk of data breaches and unauthorized access.

Challenges with EDI 834 Processing

• The EDI 834 file format is standardised and follows strict guidelines set by ANSI X12 EDI standards. However, due to its complexity, implementing EDI necessitates specialised knowledge. Insurance sponsors and payers need to have a good understanding of the EDI 834 format, as well as the technical capabilities to implement it properly.
• Continuous human intervention sometimes leads to errors.
• Although the EDI 834 format is standardised, the information contained within it can differ from carrier to carrier. This means that an EDI 834 file configured for one carrier may not be suitable for another carrier, even if they offer the same health insurance plans. This can lead to difficulties in transferring data between carriers and can increase the risk of errors. Many companies have experienced EDI 834 approaches as a black box, making it difficult to enable custom enrollment policies and rules in the software.
• Tedious and complicated monthly file processing in bulk, especially during the open enrollment period.
• The EDI 834 process requires specialised software and hardware, as well as trained personnel to implement it. Implementing EDI can be a substantial investment for insurance sponsors and payers, particularly for small and medium-sized enterprises.
• Time is wasted to eliminate the invalid or corrupt formatted files during the intake of the process.
• Files, such as transaction type and member record, that are logically out of order lead to inaccuracies in membership records.
• EDI services providers not adhering to the ANSI and HIPAA standards and rules leads to variations in data.
• Only when an entire EDI 834 membership snapshot file is shared for processing only then, the software logic determine the delta transactions.
• The sensitive nature of healthcare data requires that it be protected and secure, and this is especially important in the EDI 834 process.

The benefits of integrating EDI systems eliminate the typical process of faxing paper enrollment forms to carriers or inputting the enrollment data manually into the carrier’s website. The automated method today is more secure and accurate, eliminating the misinterpretation of manual data entry.

Also Read: How Outsourcing EDI Solution Can Help You Overcome 834 Challenges?

X12 EDI 834 Mapping & Translation

Modern EDI solution providers, like A3logics, offer end-to-end EDI solutions consisting of EDI mapping and translations, secure methods of file transmission with partners, and backend integration to simplify the transformation flows.

Conclusion

EDI 834, explained as Benefits Enrollment and Maintenance contains information about the payer, sponsor, and the member involved in offering a benefits product. This transaction set is commonly used by insurance agencies, government agencies, unions, and employers to enroll their staff members in employee benefits administration solutions. Recently, it has been most widely used in the Healthcare Industry, following the specific HIPAA 5010 standards for electronic data exchange, such as plan subscription, benefits, employee demographics information, and much more.

EDI 834 is also the core of the enrollment and maintenance transaction between insurers and federal and state exchanges. In order to change or replace the 834 formats, Congress has to introduce a new standard. Seeing that government agencies have many priorities and any regulation requires re-configuring all state and federal exchanges, we expect 834 to stay for a very long time.

The EDI 834 transactions play a crucial role in the healthcare sector by facilitating the transfer of enrollment and maintenance data between insurance sponsors and payers. The EDI 834 process provides advantages such as streamlined communication, enhanced accuracy, decreased administrative expenses, and strengthened data security. Despite these benefits, there are also challenges associated with EDI 834 processing, including the need for technical proficiency, lack of standardization, and the requirement for ongoing maintenance and updates.

Overall, embracing the use of EDI 834 transactions is a smart investment for any business looking to stay ahead of the competition and improve its bottom line. Whether you are just getting started or are looking to optimize your current EDI processes from EDI Outsourcing, understanding EDI 834 transactions is a critical step towards success.

However, with the right support and approaches from A3logics, organisations can effectively utilise EDI 834 transactions to enhance their operations and attain greater efficiency and accuracy. Acquiring a fundamental understanding of EDI 834 transactions is the initial step in unlocking the full potential of this technology in healthcare. If you’re ready to take your business to the next level, consider partnering with trusted Electronic Data Interchange providers or investing in training and resources to enhance your knowledge with the help of  A3logics. The time to act is now. Don’t wait to start leveraging the power of EDI 834 transactions to improve your business operations.