Health Plan Enrollment and Disenrollment

Under HIPAA, HHS adopted standards for electronic transactions, including enrollment and disenrollment in a health plan.

The enrollment/disenrollment transaction is the transmission of subscriber enrollment information from the sponsor of the insurance coverage, benefits, or policy to a health plan to establish or terminate insurance coverage.

It may be used in coordination with health plans for:

• New enrollments
• Changes in a member’s enrollment
• Reinstatement of a member’s enrollment
• Disenrollment of members (i.e., termination of plan membership)

The enrollment/disenrollment transaction can include a periodic full update of a health plan sponsor’s health plan enrollees, or it can reflect a change to existing enrollment with modification instructions for certain enrollees.

HIPAA Adopted Standard

HHS adopted standard ASC X12N 834 for enrollment and disenrollment in a health plan.  For more information, see the official ASC X12N website.

This standard applies to all HIPAA-covered entities, health plans, health care clearinghouses, and certain health care providers, not just those who work with Medicare or Medicaid.