What Does An 834 EDI Sample File Consist Of?

EDI 834 sample file is nothing more than a standard set by the concerned regulatory body named HIPAA and ANSI. It has a specific format according to which a transaction is made. Or, according to which a bundle of information is transmitted from one point to another.

EDI 834 sample file consists of a set of information, which could vary according to the user and purpose. It is used as a transaction set especially for ‘benefits enrollment’. 

Now depending on the, it is used for, which must be within the benefits enrollment and administration, the information consisting in the EDI 834 sample file would vary.

For example-

1. If we add new member(s) to the health plan

2. If we remove or terminate those

3. If we modify the plan

4. If we want to reinstate the recipient of the previous benefit

The 834 EDI transaction file would consist of the following information-

• The name and the identification of the concerned beneficiary

• Details regarding the benefits plan provider

• Details regarding the benefits plan including its expiry date, and other takeaways that are embedded in the specific plan.

• Plan identification or the product’s details.

EDI 834 Transaction File Is Used By-

• Employers

EDI 834 transaction file is used by employers especially to communicate with their employees for benefits administration. Apart from them, insurance agencies, government agencies which are employers, after all, are the users for the same purpose.

Moreover, EDI is a technology that consists of multiple transaction sets, for example, EDI 834, EDI 837, EDI 270, EDI 277, etc. each of them is concerned with their specific purposes.

As there are different chances when an employer needs to connect with their employees, EDI files help here to differentiate the purpose of communication.

For example, EDI 834 sample file is shared through benefits administration software to communicate about open enrollment, onboarding, and other relevant augmentation within benefits administration. The other augmentation includes disenrollment, reinstatement, etc. as mentioned in the beginning.

Similarly, as far as only the EDI 834 file is concerned, the employers have to communicate with other entities involved as well, in and around the benefits. And they are-

• The Insurance Carriers

Employers need to connect with them for specifying the type of benefits plan and to confirm the payment as a payer on behalf of its employees. The communication occurs between them using the EDI 834 transaction set only.

• The Healthcare Institutions

Whenever there is an instance in which the claim is applied for, or the reimbursement process is due, the employer seldom has to be the part of communication. To validate the necessary information regarding the claimant that involves the expiry date of the benefits plan of the claimant, his/her date of birth, etc. 

Also, the communication meanwhile the reimbursement process, which includes the claim amount requested by the claimant, and the amount processed or agreed to reimburse by the insurance carrier also occurs through EDI 834 and EDI 837 transaction sets respectively. One as a claim request, the other as a reply to that request. 

Outsourcing services of EDI help in healthcare claim status request and response as both of the transactions carry confidential information, which needs utmost confidentiality , and a safer medium to transmit through. 

EDI is the only technology available since the late 1960s that has kept on evolving to date with necessary upgrades and improvements regarding safety concerns.

All you need to have is in-house edi managed services or an EDI outsourcing service provider to keep your entire electronic transmission smooth.

• To Retirement Plans providers: 401(k)

As an employer, you would probably have senior employees too. For those, it becomes a courtesy to facilitate them with advantageous retirement plans and keep them in coordination with the 401k retirement plan providers.

• With Banks, Financial Institutions

However, the banks and financial institutions have nothing to do with the benefits administration, but there is a dimension within the same, which allows the employees to develop their savings by enrolling into such financial institutions which provide facilities like HSA i.e. Health Savings Account, and FSA (Flexible Savings Account), etc. 

Therefore, to get confirmation from them, and every update regarding their employee’s savings account modification, EDI transactions are taken into use.

Bringing our focus back to the ingredients involved in the EDI 834 transaction file, we can conclude that it would have necessary and confidential information regarding-

• Employee (the beneficiary)

• The benefits plan that he/she is enrolled in.

• The Insurance carrier

• The types of health insurance claims, some request, any detail of ratified amount, additional benefits involved in the benefits plan

• The Claim response that is executed

• The financial account concerned with the beneficiary

• The benefits broker’s identity, etc.

What makes this EDI 834 transaction set the most prevalent set around the EDI world, is its commonness. 

As far as the businesses within the United States of America are concerned, as per the top 10 edi outsourcing companies in the USA, there is no such department whose employees aren’t familiar with benefits. Also, there is no such state which does not involve insurance bodies as a part of benefits administration. 

All of the organizations have employees & their health as a common factor to think about, and a few centralized regulations in common to be compliant with. This commonness binds them to keep a few things in a singular format irrespective of their geographical location within the USA.

Thus, EDI as technology was opted as the best way to communicate, and ANSI X12 EDI along with HIPAA as regulatory bodies have worked upon creating the singular transaction sets to define distinct purposes of communication.