Healthcare EDI Transactions Real World Difference

Healthcare EDI TransactionsHIPAA The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996 as President Clinton responded to the need for more efficient healthcare services at lower costs. The solution was signing into law the Kennedy-Kassebaum Act. This act is also known as Health Insurance Portability and Accountability Act (HIPAA). It makes standards for healthcare EDI under the rules of the Department of Health.

It was not until the year 2001 when doctors, hospitals, health plans and clearinghouses begin the process of using the new healthcare EDI standards. The new legislation impacts on all data transmission within the healthcare sector. But the greatest impact has been seen in the area of security. The effects of applying the standards felt throughout the entire healthcare industry.

Key healthcare EDI transactions

837: Medical claims with subtypes for Professional, Institutional, and Dental varieties.

820: Payroll Deducted and Other Group Premium Payment for Insurance Products

834: Benefits enrollment and maintenance

835: Electronic remittances

270/271: Eligibility inquiry and response

276/277: Claim status inquiry and response

278: Health Services Review request and reply.

Healthcare EDI transactions are X12 compliant and are gathered under X12N label. Actually, they are EDI X12 4010 or 5010 release transactions. All the rules given in X12 standard manual apply to Healthcare EDI transactions.

However, there are some deviations in the standard as some healthcare EDI transactions should comply with real world requirements. A good example of this is 837 Healthcare Claim. As we know, due to different requirements there are institutional, dental and professional medical claims (subsets 837I, 837D and 837P) although officially there is only one 837 transaction in X12 standard.

You must notice that many trading partners exchange their companion guides – documents with special requirements of the definite party. These guidelines are being developed according to specific business need of a partnering company. In order to comply with such demands many companies use special software packages (mapping tools). They allow flexible validation and customization of the specific partner rules.

There are also other messages that have some deviations – EDI X12 835, 834, 810, 850, 855. The more complex the message structure is – the more possible deviations of it are in real world implementations. You can receive the same EDI transaction from different trading partners and you may notice some difference. That is why it is important to learn the specifics of the partnership and after this start electronic files exchange.

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