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
- Automates order processing and inventory management for efficient performance
- Reduce manual systems through medical EDI
- Automated transfer of data between providers and payers through EDI payment platforms
- Faster turnaround of information, reduced expenses, and delays
- Set formats for transactions, claims, eligibility, status, and payments
- Clear and systematic transaction flow
- The electronic format allows claims to be sent and received on the same day
- Eligibility checks are promptly executed, and response time is much lower
- The interoperability feature of EDI in medical billing allows information exchange with multiple payers at one time for faster transaction processes
- By using EDI in healthcare industry, it greatly benefits the organization by reducing administrative expenses on paperwork, supplies and postage costs
- Access to patient information is another powerful tool towards efficiency and faster processes
- 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 |
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