EDI HEalthcare

EDI Healthcare: Standards, Transactions, and Rules

X12 Standards

The American National Standards Institute (ANSI) formed X12 to develop and maintain the standards for XML schemas and EDI standards. X12 is a non-profit organization focused on the development and ongoing use of electronic data interchange. Their membership includes a diverse group of healthcare, insurance, and business process experts (and other industries). Members of the organization meet regularly to maintain the standards to maintain the over 320 transaction standards available for use by EDI capable organizations.

For more information on X12 visit their about X12 page.

EDI Healthcare Transaction Sets

Below is a summary of the common Healthcare EDI transactions sets in order of EDI transaction set number. Healthcare EDI software is specialy designed for HIPAA compliant processing of these transactions between trading partners

270 EDI Inquiry on Healthcare Benefit Eligibility

This transaction is used to inquire about healthcare benefits eligibility of subscriber or dependent.

271 EDI Response to Healthcare Benefit Eligibility Inquiry

Used in response to an inquiry on healthcare benefits and eligibility of a subscriber or dependent.

276 EDI Request for Healthcare Claim Status

Providers, healthcare product or services recipient (or their authorized agent) to get the status of a healthcare claim.

277 EDI Notification of Healthcare Claim Status

Used to get the claim status of a healthcare claim or encounter or additional information from a provider on a healthcare claim or encounter.

278 EDI Healthcare Service Review Information

Transmits healthcare service information. This information could be diagnosis or treatment data, subscriber, patient, or demographic. The information is requested for the review, notification, certification, or reporting the healthcare service review outcome.

834 EDI Healthcare Benefits Enrollment Transaction Set

Used to enroll members to a payer such as, an insurance company, healthcare professional, preferred provider organization, Medicare, Medicaid (or other government agency) or those contacted by the before mentioned organizations. For a more in dept look at this transaction and its sample format with our EDI 834 page.

835 EDI Healthcare Claim Payment Transaction Set

Used for payment, Explanation of Benefits remittance advice.

837 EDI Healthcare Claim Transaction Set

Used to submit billing information and/or encounter information for healthcare claims. For a more in dept look at this transaction and its sample format with our EDI 837 page.

820 EDI Healthcare Payroll Deducted and Insurance Product Group Premium Payment

Orders a financial institution to issue payment to the payee. Insurance product premium payment.

999 EDI Functional Acknowledgement Transaction Set

Provides acknowledgement of a transaction of receipt of a transaction set.

NCPDP Pharmacy Claim Transaction

Utilized by those who dispense medications, this transaction to submits healthcare retail pharmacy claims to payers.

See x12.org's full list of EDI transaction sets.

HIPAA Rules and Enforcement

  • Privacy Rule – The HIPAA Privacy Rule protects medical records and other personal health information. This rule applies to all healthcare organizations. For guidance on de-identifying PHI to meet HIPAA privacy rules requirements as well as PHI data’s permitted uses visit the HHS HIPAA guidance page
  • Breach Notification Rule– Requires the notification of breach of personal/HIPAA protected information within 60 days following the breach discovery. Visit HHS’s detailed definition of breach page for more information.
  • Rule Enforcement – HIPAA rule violations can result in civil penalties enforced by the HHS Office for Civil Rights or criminal penalties enforced by the U.S. Department of Justice. Visit the HSS rule enforcement website.

Caliber health develops T-Connect EDI software products to streamline healthcare EDI management processes for payers, providers, and intermediaries.

See the proven power of having a healthcare focused EDI software solutionContact us to schedule a live T-Connect product demo.