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 amounts 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 to exchange 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 many electronic data interchange (EDI) documents thus providing a better care giving 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

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