What is EDI in Healthcare?

Introduction to EDI in Healthcare

Healthcare EDI provides the system to securely exchange EDI documents between healthcare institutions, care providers and patients. The healthcare industry deals with enormous amount of healthcare data every day. Which includes patient medical records, medication data, emergency services records, and insurance claims.

Interoperability is the key to success for the healthcare industry with constant changes to regulatory requirements it is important for healthcare companies, vendors, suppliers, and care providers to be EDI compliant before starting exchanging EDI documents. Whether it is insurance claims, medical billing, operational processes, or data management, healthcare EDI will allow the complete supply chain to seamlessly navigate from one point to another point.

How EDI is Used in the Healthcare Industry?

EDI in healthcare automates much electronic data interchange (EDI) documents thus providing a better caregiving experience while handling complex and greater loads.

• Mapping, Translation, and Documentation – Generate healthcare documents based on EDI standards and then a request for reimbursement is made. This procedure requires the mapping of documents, which means transforming documents into the set EDI format.

• Document Validation and Testing Procedures – In this step, the documents are tested for accuracy and validated to ensure that all necessary information is present. This testing phase reduces the possibility of denied or rejected claims 

• File Transfer – The documents are then sent across a secure platform from one entity to another.  All transfers are assured to be encrypted, authentic, and secure. Compliance and regulatory rules ensure that only relevant parties receive this information
• Document Integration – The recipients are then required to translate the incoming documents into relevant formats and forward them to the specific route.

 

12 Benefits of EDI in the Healthcare Industry

1. Automates order processing and inventory management for efficient performance
2. Reduce manual systems through medical EDI
3. Automated transfer of data between providers and payers through EDI payment platforms
4. Faster turnaround of information, reduced expenses, and delays
5. Set formats for transactions, claims, eligibility, status, and payments
6. Clear and systematic transaction flow
7. The electronic format allows claims to be sent and received on the same day
8. Eligibility checks are promptly executed, and response time is much lower
9. The interoperability feature of EDI in medical billing allows information exchange with multiple payers at one time for faster transaction processes
10. By using EDI in healthcare industry, it greatly benefits the organization by reducing administrative expenses on paperwork, supplies and postage costs
11. Access to patient information is another powerful tool towards efficiency and faster processes
12. EDI documents and medical information exchanged secure protocols like AS2 and SFTP help ensure data security

 

List of EDI Transaction Codes Used in the Healthcare Industry

EDI X12 Transaction Number	EDI Transaction Name / Document Type
EDI 100	Insurance Plan Description
EDI 112	Property Damage Report
EDI 148	Report of Injury, Illness or Incident
EDI 186	Insurance Underwriting Requirements Reporting
EDI 252	Insurance Producer Administration
EDI 255	Underwriting Information Services
EDI 267	Individual Life, Annuity and Disability Application
EDI 268	Annuity Activity
EDI 270	Eligibility, Coverage or Benefit Inquiry
EDI 271	Eligibility, Coverage or Benefit Information
EDI 272	Property and Casualty Loss Notification
EDI 273	Insurance/Annuity Application Status
EDI 274	Health Care Provider Information
EDI 275	Patient Information
EDI 276	Health Care Claim Status Request
EDI 277	Health Care Claim Status Notification
EDI 278	Health Care Services Insurance/Benefit Review Information
EDI 288	Health Care Services Insurance/Benefit Review Information
EDI 362	Cargo Insurance Advice of Shipment
EDI 500	Medical Event Reporting
EDI 820	Premium Payments
EDI 834	Benefit Enrollment and Maintenance
EDI 835	Health Care Claim Payment/Advice
EDI 837	Health Care Claim
EDI 924	Loss or Damage Claim - Motor Vehicle
EDI 925	Claim Tracer
EDI 926	Claim Status Report and Tracer Reply
EDI 928	Automotive Inspection Detail