EDI Communication In Health Care Industry
Electronic data interchange (EDI) is a business-to-business, computer-to-computer exchange of transaction information, such as Health Care Claims, Payments, and Benefit Enrollment transactions. Each of these transaction types has a specifically defined, computer-readable format assigned to it.
This is referred to as a transaction set, and more than 300 such sets currently exist. For the health care industry, there are specifically 9 EDI transactions currently being used:
270 – Health Care Eligibility Benefit Inquiry and Response
271 – Health Care Eligibility Response
276 – Health Care Claim Status Request
277 – Health Care Claim Status Response
278 – Health Care Services Review – Request for Review and Response
837 – Health Care Claim Institutional
837 – Health Care Claim Dental
837 – Health Care Claim Professional
835 – Health Care Claim Payment / Advice
820 – Payroll Deducted and Other Group Premium Payment for Insurance Products
834 – Benefit Enrollment and Maintenance
The structure of EDI documents is governed by standards’ development committees such as ANSI ASC X12 and UN/EDIFACT. In the health care industry, HIPAA standards are also applied to electronic communication.
In order to understand what EDI is, it’s important to understand what EDI isn’t. EDI is not just a regular method of sending documents electronically via EMAIL or the WEB. EDI documents are standardized (according to a standards development committee) in a machine-readable format intended to be processed by an EDI Translator. For example, emailing a Health Care Claim created in Microsoft Excel or Adobe Acrobat to a payer can not be categorized as an EDI document transfer, because such process is not standardized. The caveat here is that EDI is used for computer-to-computer exchange of transactions without any human involvement.
Learn Health Care EDI basic and dive into deeper mapping practice at the EDI Academy online webinars.