Chapter 1. Purpose and Business Information

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1.1 Implementation Purpose and Scope

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For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

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The purpose of this implementation guide is to define the transaction set used to transfer enrollment information from a Health Insurance Exchange (HIX) to a Qualified Health Plan Issuer (issuer).This implementation guide will also be used for periodic reconciliation of data between an HIX and an issuer.

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The intent of this implementation guide is to meet the health care industry's specific need for the initial enrollment, enrollment response, subsequent maintenance, and periodic data reconciliation/verification of consumers who are enrolled in health insurance exchange products. This implementation guide specifically addresses the enrollment and maintenance of HIX products only.

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