EDI X12 Frequently Asked Questions
Electronic Data Interchange (EDI) is used across economic sectors and key business functions to support standardized electronic communications. Today, more than 300,000 organizations use the 300+ EDI defined transaction sets to conduct business. In healthcare, EDI X12 standards have been adopted with the aim of improving the efficiency and effectiveness of the healthcare system.
EDI parsing is the process of matching the incoming data with a defined schema to identify, flag and/or fix data transformation issues. EDI parsing errors include data type mismatches, invalid records, incorrect values, incorrect segment and element usages, etc. While EDI X12 formats are based on the published standards – in the real world, deviations and differences between EDI X12 transactions are the norm.
EDI mapping is the process through which EDI data is translated and transformed into a format more easily used or required by a trading partner or both. Data mapping is the capability to map source data fields to related target data fields in converting EDI to other formats such as XML, Excel, databases, JSON or other EDI formats.
The key EDI X12 transaction sets specified by HIPAA include:
• 837 EDI Health Care Claim and Maintenance
• 835 EDI Health Care Claim Payment/Advice
• 834 EDI Benefit Enrollment and Maintenance
• 820 EDI Payroll Deducted and other group Premium Payment for Insurance Products
• 270 EDI Health Care Eligibility/Benefit Inquiry
• 271 EDI Health Care Eligibility/Benefit Response
• 276 EDI Health Care Claim Status Request
• 277 EDI Health Care Claim Status Notification
• 278 EDI Health Care Service Review Information
• 999 EDI Functional Acknowledgement
Electronic data interchange (EDI) is the structured exchange of business documents between organizations by electronic means based on widely accepted and agreed to standards. EDI standards govern electronic data exchange in finance, government, healthcare, insurance, retail, transportation and more.
EDI is an abbreviation and shorthand for Electronic Data Interchange, a structured way to transmit data between computer systems using established message formats and standards. The businesses or organizations exchanging data are called trading partners in EDI terminology.
X12 is a standard for Electronic Data Interchange (EDI) developed and maintained by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). The X12 standard governs the exchange of business documents (e.g., purchase orders, invoices, healthcare claims, etc.) in standard electronic formats between trading partners – for example, EDI 837 Health Care Claim Transaction Set.
EDI X12 is a data format based on ASC X12 standards developed by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). It is used to electronically exchange business documents in specified formats between two or more trading partners. EDI X12 releases are known by a version number.
An EDI transaction set or EDI transaction is a group of one or more data segments representing a business document exchanged between trading partners to carry out financial or administrative activities – e.g., EDI 820 Payment/Remittance, EDI 999 Acknowledgment, EDI 834 Benefit Enrollment/Maintenance. The standard prescribes the formats, character sets and data elements used.
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 EDI X12 healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status inquiries, remittance advice and benefit enrollment.
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 EDI X12 transaction sets for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/ authorization and premium payment to health insurance plan.
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 EDI X12 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.
EDI capable is the ability to send and receive electronic business documents in a specific format based on established standards. It also refers to having in place an EDI solution that can streamline business workflows and onboard partners quickly. EDI capable can further encompass strategy and solutions that deliver efficiencies and high productivity.
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.