HIPAA EDI Rule: Clarke & Company Benefits, LLC Clarifications

The EDI Rule is intended to streamline electronic health care transactions by requiring that covered entities keep and exchange information in a uniform format. Key aspects of the EDI Rule are as follows:

Standardized transactions

The EDI Rule provides that, if a covered entity (or a business associate on its behalf) electronically conducts a covered transaction, then the entity must use standardized formats and uniform codes when conducting the transaction.

Covered electronic transactions

The following transactions are governed by the EDI Rule: health care claims or equivalent encounter information; health care payment and remittance advice; coordination of benefits; health care claim status; enrollment and disenrollment in a health plan; eligibility for a health plan; health plan premium payments; and referral certification and authorization. The Affordable Care Act (ACA) added the following transactions to the list of covered electronic transactions—electronic funds transfers and health claims attachments.

To learn more about EDI and become a certified EDI Professional please visit our course schedule page.

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