Unique Features of EDI In Healthcare
As we know, there are various standards that regulate EDI communication, and Healthcare stands different from standards for supply chain or retail. EDI standards define specific data and document formats for different transactions. In healthcare, there are nine primary EDI transaction sets:
- Eligibility benefit inquiry and response (270 and 271): Is sent by providers to payers, and payers respond (271) with either an eligibility confirmation or a reason for rejection (e.g. incomplete or incorrect format).
- Claims information (837): This transaction is used by providers to either request payment for a claim or provide encounter information.
- Payment and remittance advice (835): After a provider sends an 837 payment request, the payer will respond with an 835 transaction (to document the payment and explain any claim adjustments).
- Claim status request (276): Providers use this transaction to request the status of a previously submitted claim from the payer.
- Claim status notification (277): Is used by payers to update providers on a claim status.
- Care service review (278): Hospitals use this transaction to request prior authorization for patient service from a payer.
- Benefits enrollment (834). It is used by employers, unions, government agencies, associations, and payers to enroll new members in a health plan, manage or change their status, and remove or reinstate them.
- Payment order and remittance advice (820): Companies use this transaction to send payment instructions to banks, provide pending payment details to suppliers, and send the premium payment information to payers.
To learn more about EDI and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.