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.

Different EDI Outsourcing Scenarios Possible For A Company

Whenever we get into a business, we usually begin with a smaller scale, then we think of touching the middle-scale level, and it takes even more than we expect to reach the larger scale. Similarly, there could be different scenarios for enterprise companies in the case of EDI outsourcing in their businesses.

Writing on them one by one considering each possible scenario that a healthcare service providing company could face-

1. When The Company Is New With EDI Services

It can be the case when the healthcare business is recently set up and EDI becomes a need, especially for a healthcare business provider. EDI is a necessity for them due to standards and required singularity for easy exchange and minimal fraud existence.

In such a case, the company should first think of the type of EDI that suits its business. Whether it is Web EDI, Mobile EDI, EDI VAN, or it wants to outsource the EDI managed services?

Businesses could make the mistake of brainstorming over the service provider before focusing on the type of EDI they want to process. However, ideally, it should be the reverse.

Once you have finalized the mode or method of exchange with EDI, focusing on the specialized EDI service provider is a later task.

2. When You Need To Cost-cut The Revenue Expenditure

Things get owned when they are developed in the house. But they might then consume your time, as well as money, to keep them operating in a good manner.

EDI is a technology that demands human resources to manage it, technical support to operate and handle technical issues that are very usual in the case of online operations, and all that demands money to pay for.

EDI outsourcing would free you and your business from this headache and will offer you enough time and money to invest in other dimensions.

However, it is believed that an inflection point arrives later on when you go for a long run with EDI outsourcing, and ends up paying more than in-house EDI management. There, you must decide whether to switch back into in-house management or go straight without turning anywhere else for smoother operations.

3. When The Company Has To Do Just Once Or Twice A Year With EDI 

There exist some cases all around the globe in which EDI services are to be used seasonally or quite occasionally for the purpose of exchanging information. For example, being an enterprise software development company, it would have to share the data of the employee with the healthcare institution if the employee claims for its benefits.

Thus, in such cases, there exist similar EDI service providers that charge for occasional instances rather than for a complete year. Make sure you find a vendor like A3logics that could help you.

4. When You Do Not Want To Outsource EDI Services

EDI services are subject to cost as well as safety. The better specialization the vendor has in a specific type of EDI, the more preferable it is to hire for the same type of service.

However, it is up to the business owner whether to outsource the entire EDI requirements or to keep it within the business’s in-house EDI system. The challenges of EDI 834 resolved by EDI outsourcing is an example of such a scenario. 

5. When You Want To Switch Your Hired EDI Services/EDI Service Provider

Changing EDI vendor costs one-time charges irrespective of when and where you execute this change. However, the change could take an amount of time depending on the number of suppliers you possess or the volume of recipients you are associated to exchange data with.

Changing EDI service provider is quite similar to outsource the EDI services. It is about keeping in mind that how much it would cost as well as affect our business to switch to another EDI service distributor.

EDI service providers like A3logics are ideal abodes for businesses that require EDI services due to their dynamic nature and diverse abilities within the area of EDI. It is better than any other option to hire such an EDI service provider who possesses expertise in all types of EDI services.

6. To Stay Competitive In The Changing Market Needs

EDI outsourcing or EDI managed services are sought when you need to focus on other competitive factors that could affect your business performance. The load to carry for training the employees, assembling EDI analysts, and training the entire staff might lose your grip on other essential operations. 

Therefore, a managed EDI service provider could help you keep your business on track at fumbling market movements.

There are many other small benefits after hiring an EDI outsourcing service provider and they are as mentioned below-

• It would not demand onboarding, and scalability handling whenever the business requires to be scaled up. The outsourcing company would manage it all by itself.

• In-house EDI management would require translation support to read and extract the data, however, Cloud translation management is offered usually by EDI outsourcing partners, whereas, to inculcate this in an in-house EDI management is a cost-demanding matter.

• We all know that the Medical care industry is the biggest contributor to EDI. Suppose if there happens an EDI 834 transaction i.e. a benefits enrollment-based transaction in another country that is not in the same time zone. Here, the benefit of having EDI services outsourced is the 24*7 availability of operation handling. 

In-house management would possibly not be available at such immediate requirements due to time-based shifts. 

Concluding Statements

You may accelerate business with EDI outsourcing solutions by accomplishing the following advantages from it-

1. Reduced Operational Cost

2. Paperless business transactions

3. Minimized Administrative Cost

4. Handling Special requirements that are urgent

5. Can have a cloud-translational support system without incorporating in-house resources for it.

6. Stay compliant with regulations and free from the headache of managing it in a prompt manner.

Knowing all that, you should not remain unknown to the basic questions that must be answered by the EDI service provider on being asked by you. 

1. Can they ingest X12 files and export them to a flat-file?

2. Does the EDI Parsing process exist in their work?

3. What software do they use to convert XML to EDI and vice versa?

4. What is their take on “EDI, is now an old technology”?

5. Can they manage EDI 834 and 999 transaction complications altogether?

These are some of the questions that you may ask your EDI service provider before you hire it for a longer term. These questions would get you an idea of what experience does it hold in managing EDI services and serving cross-border clients?

Facts To Know About EDI 837, ANSI X12, and EDIFACT

EDIFACT, EDI 837, and X12 are just standards with specific purposes, predominantly used in the healthcare sector but also in top industries that use EDI for better business efficiency and responsiveness in their decision making.

These are some confusing facts about them that need clarification to distinguish between. Let us figure out them with a glance-

EDIFACT vs. ANSI X12

• EDIFACT and ANSI X12 are both functionally similar but are geographically used in different regions. 

• X12 is generally used in the American region whereas EDIFACT is seen being used in the Africa-Asian region more commonly.

• Moreover, in EDIFACT, the information would be a message whereas, ANSI X12 edi is a transaction set.

• Both are developed and supported by different organizations.

Facts about EDI 837

EDI 837 is a standard type used for the exchange of claim-based information between the healthcare provider and the insurance company.

It has nothing to confuse with EDIFACT and ANSI X12 and has 3 different types i.e. EDI 837 Q1, Q2, Q3 each for professional, dental, and institutional claim information respectively.

However, EDI 837 is often seen being confused with EDI 835, which is quite understandable because both are successive and just next to each other. 

EDI 837 can be understood as a ‘Request’ or information that is sent to the claim provider. On the other hand, EDI 835 is a ‘Reply’ to that ‘Request’ after getting well-scrutinized from the other end.

EDI 835 and 837 are quite confusing as both are related to the claim procurement process and would require better clarification to distinguish between.

Facts about ANSI X12

ANSI X12 is a global set of rules to be implemented over the EDI standards used in intercompany exchanges across the globe. The main objective of X12 is to uniform all the standards so that uniformity and singularity could be maintained all around the world at least geographically.

For example, EDIFACT and X12 both are common standards but are used in different regions which help in identifying the businesses from where they belong to.

The content that X12 consists of is of message-type and are categorically different but identified by their 3 digit identification such as-

• EDI 810- An invoice message
• EDI 820- Payment order (EFT)
• EDI 830- Delivery forecast
• EDI 832- Price/sales catalog
• EDI 846- Inventory Inquiry/Advice
• EDI 850- Purchase order
• EDI 855- Purchase order acknowledgment
• EDI 856- Ship Notice/manifest (ASN)
• EDI 860- Purchase order change
• EDI 862- Delivery Just-in-Time, etc.

All these are just types of different EDI standards uniformed to make the standards globally accepted and common for easy recognition and quick exchange.

Knowing the facts you must have a clear understanding of the three of the particular EDI attributes that are termed confusing in nature. And assuming that if someone is talking about these three of the EDI standards must have a basic idea about EDI deployment into an organization.

Usually, the healthcare software development services are familiar with edi solutions and provide adequate consultation along with 24*7 edi support. To say, A3logics has been serving as a full-fledged enterprise software development company with healthcare software as one of its niche and EDI managed services as its potential offering to its healthcare clients.

It is advised to understand EDI from the very ground level, about its requisites, about the company’s requirements and abilities to handle EDI van services, and then deploy it in a business as it has the potential to turn the business around.

How EDI 835 and 837 Are Different?

EDI 835 and 837 are two transaction types usually concerned with insurance matters. Especially in the case of claim and its application. Now, to differentiate between them we need to consider a case in which a claimant, one healthcare provider, and the insurance providing company exist altogether.

Before proceeding ahead, we need to be clear about the healthcare provider and insurance provider both, as the one which provides the healthcare facility is not necessarily the insurance provider always. 

In fact, a healthcare provider is mostly the employer which offers the healthcare service to its employee i.e. ‘the claimant’ in our case here. However, the insurance company is the one which pays when the claim is applied.

Also read the benefits of deploying a medical software and how it can help in managing claims and overall benefits administration.

Now when we are clear about the basics, let us consider the case we have assumed the characters from, the storyline would be sufficient to differentiate EDI 835 from EDI 837. Assume, there is an employee who works in an enterprise software development company based in California, USA. 

The company i.e. healthcare provider has to offer the health insurance to its employee under the healthcare act of the federal government. According to which, the employee would choose a specific health safety plan and enroll as an employee for specific benefit.

This entire process of enrolling an employee is done via EDI 834, and the overall work related to benefits is called employee benefits administration and is accomplished via different types EDI including-

• WEB EDI
• MOBILE EDI
• CLOUD BASED EDI
• EDI VAN
• EDI Managed Services, etc.
• EDI Outsourcing Services

Considering the case that the employee later requires to claim for its same health insurance. Here, the employer would send the request to the insurance providing organization for the specific amount that has been requested by the hospital or medical body. This information is to be sent via EDI 837.

Now, considering the case from the insurance providing company.

Supposing that the insurance company has received the claim request and the details about the different benefits and amount that has been claimed by the claimant.

The information would be in the form of EDI 835 transaction order and now the insurance company would scrutinize the details in it. This process generally takes a week or two.

But when the insurance company replies back or sends the aforesaid amount, whichever it finds worth sending and verifies, it sends through EDI 835.

Means, we can say that, if EDI 837 is a request order, EDI 835 is a reply to it.

• EDI 835

It is also termed as ERA or Electronic Remittance Advice. However, both EDI 835 & 837 are two transaction types but EDI 835 is an information based transaction that consists of information regarding the claim or the payment concerned with it.

• EDI 837

EDI 837, on the other hand, is the request order consisting of all the information regarding the claims that are requested by the customer or the beneficiary. However, the payment is subject to verification.

However, both EDI 835 and EDI 837 have a lot to dig upon deeply, but the basic difference that we should know is quite this much. 

Out of 400 different standards for the transaction types, EDI 8434, 835, 837 are some of the most utilized standard formats across the globe. Make sure you know EDI before deploying it into your healthcare business because things change when you keep generalized and strictly standardized stuff like EDI into a business. 

You would start getting the filtered audience which is as credible as you are after implementing EDI and its standards set by ANSI and that’s the best part as it mitigates the biggest risk of fraud influentially.