Electronic data interchange (EDI) is not just the preferred method of exchanging data in the field of healthcare. It's what's required. Enacted in 1996, HIPAA mandates that all electronic data exchanged within healthcare must exchange by way of EDI, specifically through the X12 protocol, formatted in X12 standards. The purpose of HIPAA is to bring universal efficiency to billions of data interchanges while protecting patient information.
There are many X12 standards (also known as transaction sets) applicable to various healthcare entities. Standards are exact formats data must be placed so that computers may read data. X12 standards each have a transaction set number indicating the specific purpose of the standard.
Here is an overview of 6 widely used X12 healthcare standards:
EDI 834 Benefit Enrollment and Maintenance
Employers, insurance agencies, unions, or government agencies use the EDI 834 Benefit Enrollment and Maintenance standard for healthcare benefits plan enrollment. If exchanging information electronically, HIPAA requires businesses to utilize the 834. HIPAA also mandates EDI 834 for making changes to an existing member's benefits information.
Typical uses of EDI 834:
- New member enrollment
- Changes to existing
- Termination of a member's benefits
Standard information with an EDI 834
- Name and identification information of member
- Member eligibility
- Benefit Information
- Identification of product or service
EDI 835 Health Care Claim Payment/Advice
Health insurance companies use the EDI 835 Health Care Claim Payment/Advice to electronically pay healthcare providers, as mandated by HIPAA. After the provider submits an EDI 837 Health Care Claim, the insurance company to make a payment on the charges the insurance company handles paying, as per the patients coverages. Because more than one insurance company may control costs on an 837, often multiple 835 transactions correspond to one 837.
General purposes of an EDI 835:
- Details of the charges that are being paid, denied, or reduced
- Deductible, co-pay, and co-insurance information relevant to the 837
- If claims or line items are grouped or split by payer
- Method of payment (direct from insurance company or a clearinghouse)
EDI 837 Health Care Claim
The X12 837 transaction set is the HIPAA compliant standard required to electronically submit health care claims. Providers use the 837 to invoice payers, such as government agencies like Medicaid and Medicare, as well as health insurance companies, preferred provider organizations (PPOs), health maintenance organizations (HMOs), clearinghouses, etc.
The EDI 837 typically contains the following data:
- Patient information
- Reason or symptoms for patient's treatment
- Services provided
- The charges of the treatment
EDI 274 Healthcare Provider Information
Any company that verifies or maintains healthcare provider information electronically must use the HIPAA required EDI 274 standard. The 274 is used to transmit or exchange professional qualifications and demographic information of healthcare providers. It can be used to inquire (or respond to an inquiry) on healthcare provider information or for a healthcare provider to transmit their information and qualifications.
Typical information exchanged and transmitted via the EDI 274 include:
- Applications for a provider to join a provider network, such as a PPO or HMO
- Maintenance of provider databases for the purposes of patient referrals, claim adjudication, provider information reports, and provider directories
- Verification of a provider's credentials including licenses, education qualifications, professional qualifications, and coverage and history of malpractice
EDI 275 Patient Information
The EDI 275 standard is used by healthcare companies to electronically exchange and request individual patient information. All healthcare entities must format electronically submitted patient information in the EDI 275 standard, as required by HIPAA, protecting patient confidentiality.
EDI 277 Health Care Claim Status Response
Healthcare insurance companies use the EDI 277 Health Care Status Response standard to report the status of a claim (EDI 837) submitted by a provider previously. HIPAA mandates EDI 277 as the appropriate way of submitting claim status information.
There are three ways EDI 277 may be utilized:
- In response to a received EDI 276 (Health Care Claim Status Request).
- An insurance company may request more information regarding a submitted claim using an EDI 277 without first receiving an EDI 276.
- Without first obtaining an EDI 276, an insurance company may send claim status to the provider using an EDI 277
Alpha EDI has a mapping template solution for all 6 of these X12 standards making them more accessible and user-friendly than ever. With Alpha EDI's simple, intuitive templates you save valuable time and money by mapping EDI on your own. Our Mapping templates keep you HIPAA compliant and up-to-date. We make EDI easy, so you can focus on what's important to you.