“The big moment of truth is 12 a.m. Jan.1, when a mother is standing at a pharmacy with a baby in her arms trying to get a script filled.”

- Mark Bertolini, Chief Executive of Aetna

Most people that enroll in benefits don’t know and won’t care what an 834 file is, nor should they (for the most part). But the moment of truth will be after the first of the year when new election coverage is to begin. If a mother is standing at a pharmacy waiting to get a prescription filled and can’t because she doesn’t have the correct coverage, as Mr. Bertolini references above, she will most definitely care how the file works (or in this case, doesn’t work).

An 834 EDI transmission file, known simply as an 834, is a transmission file that is the glue between enrolling a mother in benefits and then actually being able to fill a prescription at the pharmacy. It is a computer-read file that is transferred from the administrator to the carrier that contains information on who the mother is, who she is covering and what benefits she elected. This allows the insurance carrier to record her as covered, tie her dependents to her, print and mail her member ID card and eventually pay her claims.

“We are in the process of hand-matching individuals with insurance companies.”

- Kathleen Sebelius, Secretary of Health and Human Services

But just because she elected benefits, doesn’t mean the pharmacy will have record of it, as has been the case with recent healthcare.gov 834 error reports. If there is an issue within the 834 file being sent to her insurer, it could impact her coverage beginning Jan. 1.

If the 834 files aren't right, that’s a BIG deal. So who is accountable for errors in the 834 government files?

Last week at a press conference when asked who was guaranteeing coverage for participants, Kathleen Sebelius, Secretary of Health and Human Services, said, “We are in the process of hand-matching individuals with insurance companies.”

Translation: Greater chance for error, higher cost to tax payers and slower approval of coverage for many Americans.

A recent article in the Wall Street Journal noted that 834 error rates are around one in ten. Each 834 file can have hundreds of insured on it…who is going to hand-match all of these individuals? And how long will it take? Unfortunately there are very few answers to these questions from the government.

“Incorrect mapping of a participant in an 834 can lead to errors in benefits enrollment, including: incorrect coverage, no coverage at all, or incorrect participant information… It may also mean incorrect member ID cards.”

- Jeff Anderson, Senior Technical Advisor at Businessolver

Jeff Anderson, a Senior Technical Advisor at Businessolver has oversight of the company’s 834 file processes (Businessolver sends more than 2,000 each week).

When asked how incorrect 834 files can directly affect a participant, he noted, “Incorrect mapping of a participant in an 834 can lead to errors in benefits enrollment, including: incorrect coverage, no coverage at all, or incorrect participant information. It may also mean incorrect member ID cards, which could lead to increased costs to reprint and resend the member ID card (not to mention possible HIPAA violations if the wrong cards are sent to the wrong person). It is essential that mapping for benefits enrollment is tested and verified before allowing enrollment into a plan.”

At Businessolver, there is a rigorous file testing process in place, as well as a team of analysts to review, troubleshoot and verify error files in the system. Any potential issues discovered are resolved within the system, not by way of human hand-matching. Fixing the issue in the system ensures that the correct file will not be overridden in the next file send. It is also important to note that Businessolver requires the files to be tested and verified on the carrier’s end as well before they go into production.

How many test files has the government sent?

Unfortunately, mothers like the one referenced in Mr. Bertolini’s example, are going to be the innocent by-standers of the effects of incorrect 834 files of healthcare.gov if there is not a major push to get error rates to zero. Who then will the mother turn to? Who is going to hold the government accountable if coverage lapses for participants on Jan. 1, and how much red tape will it take to get through to correct the errors? It appears the real success of healthcare.gov might be the core enrollment and eligibility technology. If they can’t pass the 834 file without error, then nothing else may matter.