Medicare EDI

Medicare EDI Acronyms and Definitions

Medicare EDI terms given below are represented by acronyms and definitions as assistance to understand the Medicare EDI terminology used in health care and insurance.

  • EDI – Electronic Data Interchange – the process of using nationally established standards to exchange electronic information between business entities.
  • HIPAA – Health Insurance Portability and Accountability Act of 1996 – legislation that mandated that the healthcare industry use standard formats for electronic claims and claims related transactions.
  • MAC – Medicare Administrative Contractor – Section 911 of the Medicare Modernization Act of 2003 mandated that the Secretary for Health & Human Services replaced the contractors administering the Medicare Part A or Part B fee-for-service programs with Medicare Administrative Contractors (MACs). Part A/Part B Medicare Administrative Contractors (MACs) replaced the fiscal intermediaries and carriers and handle administration of both the Medicare Part A and Part B programs in specified geographic regions. For more information, please see the CMS overview of Medicare Contracting Reform.
  • A/B MAC – Medicare Administrative Contractor servicing both Part A and Part B lines of business.
  • DME MAC – Durable Medical Equipment Medicare Administrative Contractor
  • CEDI – Common Electronic Data Interchange – Common front end for DME MACs
  • Trading Partner – one of two or more participants in an ongoing business relationship (e.g., provider, billing service, software vendor, employer group, financial institution, etc.).
  • Submitter – an entity that owns the healthcare data being submitted. It is most likely the provider, hospital, clinic, etc. A submitter is directly linked to each billing NPI.
  • EDI Enrollment – establishes documentation specifying type of transactions and transmission methods to be used in the exchange of electronic administrative transactions.
  • EDI Registration – designates the Medicare contractor as the entity they agree to engage with for EDI and ensures agreement between parties to implement standard policies and practices to ensure the security and integrity of information exchanged.
  • Trading Partner Agreement – ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.
  • Third Party Agreement- ensures the confidentiality, security, and integrity of Medicare data being shared by third party agents that represent providers, certain value-added networks, clearinghouses, and billing agents.

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