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EDI Transactions

PilotFish Delivers Broad Support for All ASC X12 Standards and HIPPAA EDI Transactions

A surge in number of end-users such as payers, providers, pharmaceutical, and medical device industries, and others is anticipated to fuel the demand of the EDI services or solutions. Healthcare payers also use EDI for the evaluation of insurance claims before their payment settlement, risk analysis, and prevention and detection of fraudulent claims to provide rapid services through collaborating with providers in order to gain competitive advantage.

The X12 EDI format was developed by ASC X12 (Accredited Standards Committee X12), and primarily serves US industry. The X12N Insurance subcommittee of X12 develops the standards that are used for health insurance transactions in the US. The eiConsole for Healthcare X12’s Data Mapper comes equipped with an EDI Format Builder. Within the data mapper, users need only select from the EDI Format Builder’s drop-down menu to choose the transaction they want to work with. It is a simple process taking only seconds to read in the transaction. Once the transaction set is loaded, users can begin the easy drag & drop mapping process in the eiConsole for X12 Bundle.


EDI Format Builder

Click on the image for a full-size screen view.

ASC X 12 EDI usage involves message syntax and standard, messaging protocol, and transports.

EDI messages consist of an envelope and a hierarchical series of structural elements. PilotFish’s graphical Automated Interface Assembly Line process at the Data Mapper stage using XML syntax makes it very easy to transform and exchange EDI formats by employing XSLT, the W3C standard language defined to enable transformations of XML documents.

The key ASC X12 EDI transaction sets specified by HIPAA include:

  • EDI 837-Q1 Health Care Claim: Professional
  • EDI 837-Q2 Health Care Claim: Dental
  • EDI 837-Q3 Health Care Claim: Institutional
  • EDI 835-W1 Health Care Claim Payment/Advice
  • EDI 834-A1 Benefit Enrollment and Maintenance
  • EDI 820-A1 Payment Order/Remittance Advice
  • EDI 278-A3 Health Care Services Review – Response to Request for Review
  • EDI 278-A1 Health Care Services Review – Request for Review
  • EDI 277-A3 Health Care Claim Status Response
  • EDI 277-A1 Health Care Claim Status Notification
  • EDI 276-A1 Health Care Claim Status Request
  • EDI 275-A2 Patient Information
  • EDI 271-A1 Eligibility, Coverage or Benefit Information
  • EDI 270-A1 Eligibility, Coverage or Benefit Inquiry

(Note: As of 2012, healthcare providers must be compliant with version 5010 of the HIPAA EDI standards.)

EDI Message Basics

EDI messages begin with a header identifying the kind of message being sent. That header is followed by a number of components called segments. These are provided in the sequence specified by the message specification, e.g. EDI 837 Specification. Each segment is further divided into fields, which contain a value using a data type specified by the standard.  Messages, segments and fields are delimited by special characters which vary depending upon the standard. Fields may be further subdivided into components and subcomponents.  A single segment or groups of segments can repeat (these are called loops in the X12 world), allowing complex structures to be communicated.

Segments begin with a 2 or 3 letter code like ST or ISA. Some segments are mandatory, while some are not. The mandatory segments of ASC X12 are:

  • ISA – interchange header. This contains information about the sender and recipient;
  • GS – functional group header segment of a set of X12 documents of the same document type (transaction set).Includes information (codes) about the functional group: sender, recipient, and date/time.
  • ST – transaction set header segment marking the start of a transaction set
  • SE – transaction set trailer segment marking the end of a transaction set;
  • GE – functional group trailer segment of the same transaction set. Includes information on the number of functional groups and control group number: marks end of a group of transaction sets.
  • IEA – end of the interchange including interchange control reference number and information on the number of functional groups.

The hierarchical structure of an EDI message enables transaction sets/messages and groups to be batched. Even if an interchange contains only one transaction set/message and only one group, that interchange is structured with the same basic structural elements that it would have if it were batched, with the exception that there would not be multiple transaction set/message or group elements.

By embedding its deep knowledge of the X12 schemas and standards within the eiConsole and eiPlatform product suite, PilotFish delivers breakthrough productivity-boosting features that strip away the technical complexity of parsing, validating, mapping and producing ASC X12 EDI files.

For more on PilotFish’s EDI tools and resources, go to EDI Data Mapping and EDI Integration..

We invite you to take advantage of PilotFish’s full version, trial download of the eiConsole for Healthcare. Users can try out our new EDI Transformation Module and Format Builder. With the Quick Start Tutorial, users can complete an end-to-end interface in less than 20 minutes and get a true sense of the ease of use of PilotFish’s solutions and software.

For more information please call us at 813 864 8662 or click the link below to email us.

HL7 is the registered trademark of Health Level Seven International. X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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