EDI 834

Working with Benefit Enrollment and Maintenance Files

What is the EDI 834 enrollment file format?

The 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 EDI software for healthcare. 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.  Here are some EDI 834 challenges and pitfalls we’ve seen over the years.

Examples: Common Issues in Processing EDI 834 Files

  1. Large 834 EDI monthly files – Large monthly files or open enrollment periods can become processing intensive and most EDI software solutions cannot process without manual intervention and complicated parsing methods.
  2. Manual intervention – In most cases, when the EDI software or EDI parser/validation system cannot handle the complexities and high EDI volume, manual intervention is required an can become a labor-intensive and hands-on effort.
  3. Not differential – Typically, complete full EDI 834 membership snapshot files are sent for processing. It’s up to the receiver and software logic to determine the delta transactions.
  4. Variation of the EDI 834 standards – In some instances, companies or agencies do not adhere to the X12 5010 834 ANSI standards. This problem increases the complexity of processing if the EDI 834 file is not rejected back to the sending trading partner.  In some cases, you are forced to accept an invalid standard EDI 834 file and are left with the task of fixing data variations on the back end.
  5. Member matching logic – It’s very important to have member matching logic. Some EDI 834 files may contain names or NM1 values that don’t exactly match the system of record. Fuzzy matching algorithms are required to ensure membership is correct.
  6. EDI 834 membership custom rules – Most companies receiving the EDI 834 files will run their own custom rules to ensure the data is valid and to ensure benefit memberships are precise. It’s too risky to load the file as is.  Some EDI software treats the 834 as a “black box” and can be difficult to enable custom rules and policies for enrollments.
  7. Order of transaction types – An EDI 834 is prepared by many types of source systems. In many cases, the file is logically out of order which increases the complexity and accuracy of the membership records.   For example, attempting a terminate before a member was added to the plan.
  8. Members (subscribers) versus dependents out of order – Similar to transaction types, the member records can be out of order which drastically impacts EDI 834 processing accuracy. A typical pain point is that dependents aren’t always grouped under the subscriber in the family.
  9. Corrupt files – Invalid formatted files should be rejected as close to the intake process as possible. This ensures that there is no “garbage in, garbage out” data scenarios.

Template EDI 834 workflows

What if you could plug those problematic EDI 834 files into a set of pre-built solutions to avoid the challenges mentioned above?  Be sure to compare EDI software solutions that include a set of processors that can be chained together into a plug-and-play set of components.

Reorder the EDI 834 File – A “smart processing” component that reorders the file by transaction type and puts all of the Adds, Terms, Changes, and Reinstatements grouped together.  You may want to process these in a certain order based on that EDI 834 transaction type code.

Sort EDI 834 Members, Subscribers, and Dependents – Another T-Connect component can sort the file and put all dependents and subscribers in a configured order.  This ensures you are processing benefits enrollments by family.

Split EDI 834 by Transaction Type (Adds, Changes, Terms, Reinstatements) – T-Connect not only sorts and reorders the file, but it can also split up the file by transaction type.  T-Connect will split a single large EDI 834 enrollment file into 4 files – Adds, Changes, Terms, and Reinstatements.

Split EDI 834 by Record Count – Some adjudication or destination systems cannot handle the data volume included in the EDI 834 file.  T-Connect can split in many configurations so that your destination system can safely process large EDI 834 files.  This component can also throttle the delivery of files.

EDI 834 Membership Lookup and Custom Enrichment Rules – T-Connect provides an EDI API built for .NET Framework and .NET Core.  You can then easily build custom rules and policies in C# to ensure the EDI 834 data is being processed according to your established rules.

EDI 834 Delta File Generator – EDI 834 files are typically full snapshots with most of the data unchanged from month/week to month/week.  Wouldn’t it be nice to run that through a “delta file generation” component and just process the transactions that changed since the last time the file was sent?

EDI 834 enrollment file workflows

In the below illustration, we demonstrating the receipt an EDI 834 file from a clearinghouse or provider and put it through some of the EDI software components listed from above.  We call this collection of components our “834 Enrollment Optimizer” suite.  To learn more about this solution check out our Compare EDI Software page and find the right EDI 834 processing solution for your company.

Figure: EDI 834 Sample Workflow

Image

EDI 834 time to market

With the right EDI Software, organizations can replace or work in conjunction with their existing legacy EDI system.  T-Connect is very non-invasive and can be installed in less than 1 day.  If you only need a EDI 834 processor, you don’t have to buy functionality for the other transaction set types.  We offer the solution in a SDK for Developers product that is C# .NET object based with APIs, a Database with Developer SDK, and our EDI Gateway solution with management screens for EDI analysts and developers.  Install T-Connect on modest commodity sized hardware and take advantage of the power and speed of the solution.  In some cases, we offer a trial installation so that you can be comfortable the system will drastically improve your EDI 834 processing.

Caliber Health’s mission is to make EDI easy for people and computers with innovative technology, experience, and unmatched service. Contact Caliber Health today to solve your team’s EDI processing challenges and grow your organization’s competitive advantage. Click the button below to explore our T-Connect EDI software solutions and discover more EDI processing insights on our Caliber Health Blog.