Back to Pilotfish Home

Healthcare EDI FAQ

Healthcare EDI Frequently Asked 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.

HL7, EDI & FHIR Data Integration for Reporting & Analytics with PilotFish

HL7, EDI & FHIR Data Integration for Reporting & Analytics

4. What are the HIPAA X12 transaction sets?

The key X12 EDI transaction sets specified by HIPAA include:

 EDI 837 Health Care Claim and Maintenance
 EDI 835 Health Care Claim Payment/Advice
 EDI 834 Benefit Enrollment and Maintenance
 EDI 820 Payroll Deducted and other group Premium Payment for Insurance Products
 EDI 270 Health Care Eligibility/Benefit Inquiry
 EDI 271 Health Care Eligibility/Benefit Response
 EDI 276 Health Care Claim Status Request
 EDI 277 Health Care Claim Status Notification
 EDI 278 Health Care 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 EDI 837 in healthcare?

EDI 837 Healthcare Claim transaction set and format have been specified by HIPAA for the electronic exchange of healthcare claim information. Providers send the 837 transaction set to payers who are the third party entities that pay claims or administer the insurance product or benefit or both. Read our EDI 837 Claims Integration Case Study.

8. 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.

9. 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.

This is a unique website which will require a more modern browser to work! Please upgrade today!