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Healthcare EDI FAQ

Healthcare EDI Questions

1. What is healthcare EDI?

Most commonly, healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) rules requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status inquiries, remittance advice and benefit enrollment.

2. What is HIPAA EDI?

In the electronic exchange of financial and administrative healthcare transactions, the Health Insurance Portability and Accountability Act (HIPAA) requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/ authorization and premium payment to health insurance plan.

3. What are healthcare EDI transactions?

In EDI, a single business document is called a “transaction set” or “message.” HIPAA requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for structured message exchange. Electronic transactions covered include healthcare claims, claims status and remittance advices, eligibility verifications and responses, referrals and authorizations, and coordination of benefits.

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4. What are the HIPAA X12 transaction sets?

The key X12 EDI transaction sets specified by HIPAA include:

 EDI 837 Healthcare Claim and Maintenance
 EDI 835 Healthcare Claim Payment/Advice
 EDI 834 Benefit Enrollment and Maintenance
 EDI 820 Payroll Deducted and other group Premium Payment for Insurance Products
 EDI 270 Healthcare Eligibility/Benefit Inquiry
 EDI 271 Healthcare Eligibility/Benefit Response
EDI 275 Patient Information
 EDI 276 Healthcare Claim Status Request
 EDI 277 Healthcare Claim Status Notification
EDI 277 Healthcare Claim Acknowledgment
 EDI 278 Healthcare Service Review Information
 EDI 999 Functional Acknowledgement

5. What X12 EDI supply chain transactions are used in healthcare?

Common Types of X12 EDI Supply Chain Transactions include:

 EDI 180 Return Notification and Authorization
 EDI 810 Invoice
 EDI 820 Payment Order and Remittance Advice
 EDI 832 Price/Sales Catalog
 EDI 846 Inventory Inquiry and Advice
 EDI 850 Purchase Order
 EDI 855 Purchase Order Acknowledgment
 EDI 860 Purchase Order Change
 EDI 864 Text Message
 EDI 997 Functional Acknowledgment

6. How does EDI work in healthcare?

Healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status, remittance advice and benefit enrollment.

7. What is an EDI claim?

HIPAA X12 EDI transaction sets are structured messages standardized and required for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/authorization and premium payment to health insurance plans by all health plans, healthcare clearinghouses and healthcare providers.

8. How does EDI work in medical billing?

EDI allows entities within the healthcare ecosystem to exchange medical, billing and other information quickly and cost effectively. Medical billing involves timely exchange of specific HIPAA EDI documents (claims, remittance advice, eligibility inquiry, claim status inquiry), accurate medical coding, and secure information exchange to and from provider and payer entities as well as third-party vendors and clearinghouses.

9. What is EDI 270 Eligibility, Coverage of Benefit Inquiry?

The EDI 270 transaction set and format is used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or dependent under the subscriber’s policy. The transaction set may be used by all lines of insurance such as Health, Life, and Property and Casualty. For more detailed information see EDI 270 format and example.

10. What is EDI 271 Eligibility, Coverage of Benefit Information?

The EDI 270 transaction set and format is used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as – insurers, sponsors, payors) to information receivers (such as – physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, co-insurance, co-pays, deductibles, exclusions and limitations. For more detailed information, see EDI 271 format and example or read this EDI 271 integration case study.

11. What is EDI 275 Patient Information?

The EDI 275 transaction set is used to communicate individual patient information requests and patient information between separate health care entities in a variety of settings to be consistent with confidentiality and use requirements. Patient information consists of demographic, clinical, and other supporting data. The EDI 275 can be sent either solicited or unsolicited. The EDI 275 Patient Information is an EDI transaction designed to carry attachments. For more detailed information, see EDI 275 format and example.

12. What is EDI 276 Healthcare Claim Status Request?

The EDI 276 transaction set is used by a provider, recipient of healthcare products or services, or their authorized agent to request the status of a healthcare claim or encounter from a healthcare payer. Note: EDI 276 does not replace the EDI 837 Healthcare Claim transaction set, but is intended for use after the receipt of a claim or encounter information. Such a request may occur at the summary or service line detail level. For more detailed information, see EDI 276 format and example.

13. What is EDI 277 Healthcare Claim Status Notification?

The EDI 277 is used by a healthcare payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a healthcare claim or encounter or to request additional information from the provider regarding a healthcare claim or encounter, healthcare services review, or transactions related to the provisions of healthcare. The notification may be solicited or unsolicited. EDI 277 does not replace the Healthcare Claim Payment/Advice Transaction Set (EDI 835). It is not used for account payment posting. The notification may be at a summary or service line detail level. For more detailed information, see EDI 277 format and example.

14. What is EDI 277 Healthcare Claim Status Response?

The EDI 277 is Acknowledgement/Returned as Unprocessable Claim-The claim/encounter has been rejected and has not been entered into the adjudication system. The EDI 277 transaction set has been specified by HIPAA for the submission of claim status information to respond to a previously received EDI 276 Claim Status Inquiry, to request that a payer provide additional information about a submitted claim (no 276 involved), or for a payer to provide claim status information to a provider via the EDI 277, without having received a 276.

15. What is EDI 277CA Healthcare Claim Acknowledgment?

The EDI 277CA Healthcare Claim Acknowledgment provides a claim level acknowledgment of all claims received in the payer’s pre-processing system before submitting claims into an adjudication system. It is created in receipt of an incoming EDI 837 5010 claim submission transaction. The 277CA offers a common report interface to payers and providers. Most clearinghouses and payers now use the 277CA as their standardized reporting mechanism for 5010. The 277CA reports on whether pre-adjudication validation found the claims acceptable for adjudication. There are no Category Codes signifying ‘accepted with warning’. The 277CA cannot report syntax issues. The EDI 277CA transaction is not required by HIPAA. For more information, refer to the TR3 Implementation Guide (Technical Report Type 3).

16. What is EDI 278 Healthcare Services Review Request?

The EDI 278 transaction set can be used to transmit healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

17. What is EDI 278 Healthcare Services Review Response to a Request?

The EDI 278 transaction set can be used to responses to requests for healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

18. What is EDI 820 Payment Order/Remittance Advice?

The EDI 820 transaction set can be used to make a payment, send remittance advice, or make a payment and send remittance advice. This transaction set can be an order to a financial institution to make a payment to a payee. It can also be a remittance advice identifying the detail needed to perform cash application to the payee’s accounts receivable system. The remittance advice can go directly from payer to payee, through a financial institution, or through a third-party agent. For more detailed information, see EDI 820 format and example or read this EDI 820 integration case study.

19. What is EDI 824 Application Advice?

The EDI 824 acknowledgment is used as a means of communicating errors in a previous transaction. The EDI 824 report allows the trading partner who sent the original transaction to identify, correct and resubmit that transaction. In healthcare applications, the optional EDI 824 transaction meets HIPAA 5010 requirements for non-claims (EDI 276, 270 and 278) transactions. In practice, EDI 824 is used or even required as an acknowledgment to EDI 837 Claims as well. The 824 acknowledgment also is used report the success of failure of an EDI 275 attachment transaction. The 824 can embed an HL7 report on the acceptance of the HL7 or identifying specific HL7 syntax errors. For more detailed information, see EDI 824 format and example.

20. What is EDI 834 Benefit Enrollment and Maintenance?

The EDI 834 transaction set can be used to establish communication between the sponsor of the insurance product and the payer. The sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, etc.), or an entity that may be contracted by one of these former groups. For more detailed information, see EDI 834 format and example or read the EDI 834 integration case study.

21. What is EDI 835 Healthcare Claim Payment & Remittance Advice?

The EDI 835 Healthcare Claim Payment and Remittance Advice transaction set is used by insurance plans to make payments to healthcare providers and/or provide Explanations of Benefits (EOBs) remittance advice. When an EDI 837 Healthcare Claim is submitted by a healthcare service provider, the healthcare insurance plan uses the EDI 835 to detail the payment to that claim. What charges were paid, denied, or adjusted; the presence of a deductible, co-insurance, co-pay, etc.; bundling or splitting of claims or line items; how payment was made (e.g. clearinghouse). Healthcare providers use the 835 to track what payments were received for the services they provided and billed. For more detailed information, see EDI 835 format and example or read this EDI 835/837 revenue recovery case study.

22. What is EDI 837 Healthcare Claim: Professional?

The EDI 837 or 837P transaction set is used for electronic claims from providers and health plans for services performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services. This transaction set is sent by the providers to payers, which include insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), or government agencies such as Medicare, Medicaid, etc. These transactions may be sent either directly or indirectly via clearinghouses. For more detailed information, see EDI 837 format and example or read this EDI 837 integration case study.

23. What is EDI 837 Healthcare Claim: Dental?

The EDI 837 or EDI 837D transaction set is used for electronic claims from providers and health plans that use EDI for dental procedures. EDI 837D can be used to submit dental claim billing information, encounter information, or both. Submitters can be providers of approved categories of dental care to payers, either directly or via intermediary billers and claims clearinghouses. For more detailed information, see EDI 837 format and example.

24. What is EDI 837 Healthcare Claim: Institutional?

The EDI 837 or EDI 837I transaction set is used to transmit institutional claims submitted by hospitals and skilled nursing facilities. EDI 837I can be used to submit healthcare claim billing information, encounter information, or both. Submitters can be providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses. For more detailed information, see EDI 837 format and example.

25. What is EDI 997 Functional Acknowledgment?

The EDI 997 Functional Acknowledgment describes the syntax-level acknowledgment of the receipt of an X12 functional group. It confirms to a sender that a receiver has received the EDI transactions successfully. In addition, the acknowledgment contains an acceptance or rejection notification. HIPAA EDI Version 5010 of the standards established EDI 999 as the healthcare standard acknowledgment document, designed to replace Version 4010 997 Functional Acknowledgment. You may encounter both the 997 and 999 in use. For more detailed information, see EDI 997 format and example.

26. What is EDI 999 Implementation Acknowledgment?

The EDI 999 transaction set is used to define the control structures for a set of acknowledgments to indicate the results of the syntactical and relational analysis of the electronically encoded documents, based upon a full or implemented subset of X12 transaction sets. EDI 999 does not encompass the semantic meaning of the information encoded in the transaction sets. For more detailed information, see EDI 999 format and example.

27. What is EDI TA1 Interchange Acknowledgment?

The EDI TA1 Interchange Acknowledgment is used to verify the syntactical accuracy of the envelope of the X12 interchange. The TA1 will indicate that the file was successfully received as well as indicate what errors existed within the envelope segments of the received X12 file. The TA1 verifies the envelope only. For more detailed information, see EDI TA1 format and example.

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