Today’s healthcare ecosystem relies on efficient information exchange to deliver quality care. Electronic Data Interchange (EDI) serves as the backbone of this information exchange, enabling healthcare providers, insurers, and other stakeholders to communicate seamlessly.
EDI transactions in healthcare are crucial in more ways than one. This blog looks at the most commonly used ones with a complete overview of their purpose, sender, and receiver.
The Fundamental Role of EDI in Healthcare
The healthcare EDI ecosystem facilitates the exchange of standardized electronic documents between various stakeholders, replacing traditional paper-based processes. These digital transactions streamline everything from patient eligibility verification to claims processing and payment reconciliation. Plus, stakeholders in the healthcare ecosystem are legally required to ensure HIPAA compliance, which is done through the use of ANSI X12 EDI standards, further cementing the criticality of EDI.
Overview of Common EDI Transactions in Healthcare
EDI transactions in healthcare are used for a variety of purposes. However, whatever their purpose, these transactions are crucial in holding the healthcare ecosystem together by connecting healthcare providers, insurers, and pharmacy networks.
The following table details critical EDI transactions in healthcare, providing a clear picture of the sender, receiver, and purpose of each transaction:
EDI Transaction |
Sender |
Receiver |
Description |
| EDI 270 | Healthcare provider or billing service | Health insurance payer | Requests information about a patient’s eligibility and benefits from a health insurance payer. |
| EDI 271 | Health insurance payer | Healthcare provider or billing service | Responds to the eligibility inquiry (EDI 270) with detailed information on a patient’s eligibility and benefits. |
| EDI 275 | Healthcare provider or billing service | Health insurance payer | Sends patient demographic and administrative information, such as updates or corrections. |
| EDI 276 | Healthcare provider or billing service | Health insurance payer | Asks for the status of a submitted claim. |
| EDI 277 | Health insurance payer | Healthcare provider or billing service | Responds to the claim status request (EDI 276) with detailed information about the status of a submitted claim. |
| EDI 278 | Healthcare provider or billing service | Health insurance payer | Requests prior authorization for specific healthcare services or procedures. |
| EDI 820 | Payer or employer | Healthcare provider or billing service | Sends premium payments and associated remittance advice. |
| EDI 824 | Receiver of the original transaction | Sender of the original transaction | Provides acknowledgment and notification of the status of an application or transaction, confirming receipt, acceptance, rejection, or pending status. |
| EDI 834 | Employer, benefits administrator, or health plan | Health insurance payer | Communicates enrollment and maintenance information, such as adding or terminating coverage. |
| EDI 835 | Health insurance payer | Healthcare provider or billing service | Sends remittance advice and payment details for services rendered. |
| EDI 837-P | Healthcare provider or billing service | Health insurance payer | Submits professional healthcare claims for services provided by healthcare providers such as physicians and therapists. |
| EDI 837-D | Dental care provider or billing service | Dental insurance payer | Submits dental healthcare claims for services provided by dental care providers. |
| EDI 837-I | Institutional healthcare provider or billing service (e.g., hospitals, nursing homes) | Health insurance payer | Submits institutional healthcare claims for services provided by hospitals, nursing homes, and other institutional facilities. |
| EDI 837-COB | Healthcare provider or billing service, or primary insurer | Secondary insurance payer | Submits healthcare claims involving coordination of benefits, detailing payments made by the primary insurer and requesting additional payment from the secondary insurer. |
| EDI Retail Pharmacy Claim Transaction (NCPDP) | Pharmacy or pharmacy benefits manager (PBM) | Health insurance payer | Submits retail pharmacy claims for prescription drugs to health insurance payers. |
| EDI 997 | Receiver of the original transaction | Sender of the original transaction | Provides functional acknowledgment indicating the receipt and basic validation of an EDI transaction, confirming whether the original transaction was received and accepted or rejected. |
| EDI 999 | Receiver of the original transaction | Sender of the original transaction | Provides implementation acknowledgment with detailed validation results for the original transaction, specifying errors, warnings, or acceptances related to the received transaction. |
| TA1 | Receiver of the interchange (EDI file) | Sender of the interchange (EDI file) | Provides acknowledgment of the interchange. |
Conclusion
To sum up our discussion so far, EDI transactions in healthcare serve as the thread that keeps the entire ecosystem interconnected. Healthcare stakeholders including care providers, insurance companies, pharmacy networks and other third-party suppliers and intermediaries all rely on these transaction sets to exchange critical information efficiently and accurately.
However, effectively managing EDI transactions in healthcare requires a robust solution that balances customization, compliance, and ease of use. That’s where HealthEDI comes in.
The HealthEDI Advantage: Purpose-Built for Healthcare
HealthEDI provides a specialized solution designed specifically for healthcare EDI transaction processing, offering the perfect balance between customization and maintenance-free operation.
Key Benefits of HealthEDI
- Healthcare-Specific Compliance: HealthEDI maintains current knowledge of healthcare regulatory requirements with automatic updates.
- Unlimited Scalability: Our platform handles any transaction volume efficiently, from small practices to large health systems.
- Zero Maintenance Burden: Our team handles all system maintenance and updates, allowing your staff to focus on core functions.
- Complete Customization: Unlike generic solutions, HealthEDI can be tailored to match your specific business processes.
- Seamless Integration: Our platform connects easily with your existing systems through our advanced API architecture.
Power Your EDI Transaction Processing with HealthEDI
HealthEDI offers the ideal balance between customization and maintenance, providing a powerful platform that handles the complexities of healthcare EDI transactions while offering the flexibility to meet your organization’s specific needs. With HealthEDI, you can ensure that critical healthcare information is exchanged accurately, securely, and efficiently throughout your entire business ecosystem.
View a demo or connect with our team to discuss how we can help streamline your EDI processing.
