HIPAA EDI Standards, transactions, and rules.


EDI Healtcare Process Overview

Why are HIPAA EDI standards important?

Healthcare organizations must keep track of an enormous amount of data. Patient health records, treatment, and identifying information must be kept private. Managing data all that data is a challenge for any organization. Healthcare IT teams work hard to make sure data transmitted securely and accurately. Electronic Data Interchange (EDI) is used as the preferred communication method between trading partners.

Better Data Transmission Accuracy

HIPAA EDI transactions standardized the way we transmit member benefit facilitation data. Common healthcare document types are categorized into HIPPA EDI transactions sets. For example, healthcare EDI claims are transmitted via 837 file format. However, payment information is communicated via the 835 HIPAA EDI transactions type.

Saving time and reducing costs

HIPAA EDI standards help to facilitate paperless data exchange. This is especially true for healthcare organizations. X12 data can be analyzed to improve the quality of care. Healthcare EDI software is a commonly used to manage the data workflows. Transaction data is parsed to databases for reporting. These solutions incorporate storage, routing, reporting, and SNIP level validations. The process is improved by utilizing relational databases in healthcare.

HIPAA EDI Standards impact electronic data interchange.

EDI processing must comply with HIPAA EDI standards in order to exchange documents electronically. These x12 transactions are sent in X12N format between trading partners. HIPAA EDI transactions, such as the EDI 834, transmit benefits data. This X12 data transmission can come in the form of claims or other healthcare transaction types. Common healthcare EDI capable organizations include providers, payers, and third-party benefits administrators. HIPAA documents are converted to a standard computer (non-human readable) language. X12N transaction codes are assigned to each documentation set for easier identification.

Using software to assist in data exchange

Healthcare EDI software enables better management of data flows into and out of an organization. It’s common for medical and health insurance organizations to implement EDI software. Implementing these solutions enable the secure transfer of healthcare data. EDI solutions are used to manage data exchange between business partners.  This connection process opens the path for secure information exchange.

X12 format is extremely efficient in computer-to-computer communication. ANSI ASC X12 is the organization that sets the universal standards for EDI formatting. Onboarding trading partners is the process of configuring a connection to communicate using this format. EDI Capable healthcare organizations see extreme cost reduction. Electronic data interchange reduces human data touchpoints and the associated risk of data entry errors.

What are the HIPAA EDI Standard Rule Sets?

Healthcare systems follow HIPAA laws to be more effective. The Health Insurance Portability and Accountability Act was signed into law by former president Bill Clinton. It carries provisions to simplify administration and requires the Secretary of the Department of Health and Human Services (HSS) to adopt 5010 standards. HIPAA standards require healthcare transaction formats, code sets, unique health identifiers, and security rules.

Healthcare data transfer is regulated by federal privacy protections for patient identifiable information. When processing HIPAA EDI transactions security provisions be in place for safeguarding medical information. This regulation came in response to data breaches and cyberattacks on providers and healthcare payers.

HIPAA EDI Standards rule sets:

  • Privacy Rule sets provide national standards for health plans, clearinghouses, and treatment providers. These apply to organizations conducting standardized electronic healthcare transactions.
  • Security Rule sets protect confidentiality, integrity, and availability of electronic protected health information.
  • Enforcement Rule sets provide standards for the enforcement of all the administrative simplification rules.

It’s easy to see the critical role HIPAA law plays in protecting the right to privacy.  It also simplifies designation of healthcare benefits coverage, treatment, and payment.

Centers for Medicare & Medicaid Services (CMS) provides tools to help determine if your organization is considered a HIPAA covered entity. The information protected is referred to as protected health information data. PHI data includes eighteen unique patient protected patient identifiers.

HIPAA EDI standards influencing organizations

American National Standards institute – ASC X12 is a non-profit healthcare EDI standards forum founded in 1918. ANSI administers and coordinates the U.S. voluntary standards and conformity assessment system. They are trusted to facilitate the partnership between the public and private sectors. ANSI continually organizes committee meetings to address gaps in existing healthcare EDI standards.

Accredited Standards Committee for X12 - ASC X12 is a committee chartered by ANSI in 1979. The EDI standards focused organization sets US standards body for X12 electronic data Interchange. Their membership includes technologists and business process experts from industries including healthcare, insurance, and government. Their X12N Insurance division develops and maintains healthcare EDI formats. These transaction set types are used for the insurance industry’s business activities.

National Council for Prescription Drug Programs -NCPDP is a not-for-profit ANSI accredited organization based in the United States. The organization acts as a multi-stakeholder, problem-solving forum for the healthcare industry. They focus on developing and promoting industry standards for prescription drug programs. They work to improve patient outcomes and decrease the cost of care. NCPDP standards are named in federal legislation including MMA, HIPAA, HITECH and Meaningful Use.

Workgroup for Electronic Data Interchange – WEDI was formed in 1991 and has become the leading authority on the use of Health IT. They focus on the use of technology to improve healthcare information exchange. WEDI is a named advisor to the Department of Health and Human Services. They facilitate a coalition that represents a cross-section of the healthcare EDI industry. They represent doctors, hospitals, laboratories, pharmacies, dentists, clearinghouses, and software vendors.

HIPAA EDI transactions - healthcare transaction set types 


EDI 837 files are claims transactions that transmit treatment data between entities for coordination of benefits. EDI 837I format is used by healthcare Institutions. EDI 837P format is used by healthcare providers. EDI 837D format is used for dental claims. X12 formatted claim transactions are sent from providers to TPAs or insurance payers. This could also be between regulatory agencies for healthcare insurance benefits coordination.


EDI 835 files are healthcare claim payment and remittance advice files used by payers to pay for healthcare services. These are typical services rendered to plan members by the billing provider or institution. 835 transactions are sent directly from the health benefits payer or through a financial institution. This X12N transaction is used in response to an 837-claim file. 835s are used to make a claim payment or send an explanation of benefits remittance advice.


EDI 834 files are healthcare benefits enrollment and maintenance transactions. Enrollments are commonly used by employers, government agencies, unions, and insurance agencies. 834 files facilitate the enrollment of members to a payer’s medical benefits plan. Healthcare EDI payers can be preferred provider organizations, government agencies, or any contracted organization.

Group Premiums

EDI 820 files are payroll-deducted and other-group premium payments for insurance products. This X12 transaction is used to pay for insurance products. It is specifically for plan sponsors or companies providing healthcare benefits. A financial institution can receive an 820 as order of payment to a payee. 820 transactions are typically used by businesses to provide payment instructions. They are read by banks, individual suppliers, or insurance plans.


EDI 270/271 files are healthcare eligibility or benefit inquiry and response transactions. These are inquiring about health care benefits coverage or benefits eligibility. 270 transactions are typically associated with a subscriber or dependent. 271 healthcare EDI transactions are responses from payers regarding benefit eligibility.

Status Updates

EDI 276/277 files are healthcare claim status requests and updates. 276 transactions are typically used by providers or recipients of healthcare products or services to request the status of a claim. 277 transactions are used by payers to let a provider know the status of a claim.

Services Review

EDI 278 files are healthcare service review information transactions. These X12N transactions transmits health care service information. This data can be for review requests and notification or reporting of a health care services review.


EDI 999 files are HIPAA implementation acknowledgement transactions. 999 transactions act as responses confirming the receipt and reading of a healthcare EDI transaction. It can report the exact syntax related issue that caused errors. It notifies the sender if the file was accepted or rejected. Rules are in place to make sure files received meet standards and formatting guidelines of the payer. EDI validation software is used to help to ensure acceptance or rejection based on these validation rules. Acknowledgements indicate A- Accepted, R- Rejected, or E- Accepted with errors.

Learn how Caliber Health’s Healthcare EDI Solutions can help your healthcare organization remain EDI X12 and HIPAA 5010 compliant.  Contact us to schedule a live Healthcare EDI Software product demo.