The basics of an EDI 834 file for third-party administrators
As a third-party administrator, you’ve likely worked with an EDI 834 file in the past. If the process is not currently automated in your organization, you are typically manually sending enrollment data to the carrier, which can result in costly errors if the information is inputted incorrectly. Let’s break down what an 834 file is, how it’s used and why it’s important to automate.
What is an EDI 834 file?
Simply, an EDI 834 file is a benefit enrollment and maintenance document that must abide by HIPAA 5010 standards. This file is used by a multitude of organizations, such as employers, TPAs and insurance agencies, for enrolling their members directly into a benefit plan.
The 834 file includes demographic information on the employee, including the plan subscriber’s name, plan network information, eligibility and benefit information.
For third-party administrators, an EDI 834 file is commonly used to add, remove or update member’s enrollment information. The information submitted can be new member or dependent enrollments, adjustments to their current enrollment, reinstatement or disenrollment after the plan is terminated.
Once an 834 transaction is received, the recipient must respond back with a 999 Implementation Acknowledgement. This acknowledgment must also be HIPAA 5010 compliant and will provide information back on the acceptance of the document. The 999 will commonly include whether it was accepted, rejected, or accepted with errors.
Aside from EDI 834, what are the other enrollment data file types?
Outside of the 834 standard, many vendors choose to implement their own data formats for moving enrollment data. Some common examples include anything from XML, CSV, to even Web Services via SOAP or JSON.
What do you do if EDI 834 is not available?
We created a solution to meet this challenge–our Claims & Enrollment Integrations solutions.
TPA Stream has experience and expertise in consuming and producing a wide variety of vendor formats. We work with data from vendors like Employee Navigator, Alegeus, WEX Health, and many more. The integration manager does much more than import and export data between software systems. Our solution is designed to keep your process running smoothly with error reporting, file status updates, and more.