EDI Connect for HIPAA Integration

EDI Connect for HIPAA Integration

Lets first start by examining the two namely what is EDI and what are HIPAA standards after which we will proceed to integrate the two.

EDI – stands for Electronic Data Interchange. These are standards provided by IETF(Internet Engineering Task Force) and deal with document handling data flow between the parties that deal with the data transmission , data being transmitted electronically or physically. Initially developed for the automotive industry EDI has been made technology independent as well as communication technology independent.

HIPAA– Stands for Health Insurance Portability and Accountability act is a legislation active in United States which safeguards medical information of individuals. Split up into HIPAA 1-V the parts that are relevant are HIPAA II which specifically deal with national standards for processing electronic healthcare transactions

Thus HIPAA II deals guidelines regarding Identification, EDI standards, Privacy Rules, Security Rules and Enforcement of these rules.

Identification – Each of the entities eg individuals, employees, health plans and providers have a unique 10 digit number.

EDI Standards – Electronic Transactions are standardized when used by entities which are parts of the chain example health care providers, physicians and clearing houses.

  • Privacy Rules – National standards to protect the patient health information.

  • Security Rules – Sets standards for Patient data security.

  • Enforcement Rule – Sets rulesets for HIPAA security violations.

HIPAA EDI standards

EDI X12 is a data format based on ASC X12 standards. Mostly X12 is used to interchange data between two or more partners, organizations or companies.

Due to the industry being very fragmented with various data formats it was better to come out with a single format that would do away with this very issue The EDI rules govern the way data is transmitted from one computer to another.

EDI X12 is a data format based on ASC X12 standards. Mostly X12 is used to interchange data between two or more partners, organizations or companies. HIPAA uses the X12N standards split up into subcommittees which deal with the following – X12C Communications & Controls, Finance, Transportation, Technical assessment, Supply Chain, Insurance.

Example of a EDI X12 file.

When EDI is used there are strict rules as to where the formatting is. These rules will define where the element is in a file. Whenever an EDI translator reads a file it will know where exactly to find the elements in the file. Then, that data will be fed into the receiver’s order entry system in the proper internal format without requiring any manual order entry.

Example of a Purchase order and the corresponding EDI files.

In the EDI language, a single business document, such as a purchase order, invoice or advance ship notice, is called a “transaction set” or “message.” And, a transaction set is comprised of data elements, segments and envelopes.

  • Data Elements – These are the individual items of information in the document.

  • Segments – Data Elements are combined into segments. Eg similar data elements.

  • Envelopes – EDI uses three envelopes to house transaction sets. Transaction set, Group of transaction set placed in a Group envelop and finally the Interchange Envelope which comprises of all envelops being sent from one sender to one receiver are placed in an interchange envelope.


So far we have dealt with EDI and HIPAA separately. We will now list important EDI transactions which are used in HIPAA

  • EDI 837 – Medical claims with subtypes for professional institutions and dental varieties

  • EDI 820 – Payroll deducted and other group premium payment for insurance products

  • EDI 834 – Benefits enrollment and maintenance.

  • EDI 835 – Electronic remittances

  • EDI 270/271 – Eligibility enquiry and response

  • EDI 276/277 – Claim status enquiry and response

  • EDI 278 – Health status review request and reply

EDI 837 – The claim information included amounts to the following, for a single care encounter between patient and provider:

  • Patient description, condition, service provided, cost of treatment.

  • EDI 820 – Used for payment of goods, insurance premiums or other transactions.

  • EDI 834 – Used by employers, unions, government agencies and insurance agencies to enroll members in a health care benefit plan.

  • EDI 835 – Details of the payment claim as to charges paid, denied, deductible, co-insurance, bundling, splits etc ,

  • EDI 270/271 – EDI 270 is used to inquire about the health care eligibility and benefits,271 used to get the response for the same.

  • EDI 276/277 – EDI 276 used to inquire about the claims status after sending it to a payer, 277 used to get the response for the same.

  • EDI 278 – EDI 278 is used to submit information regarding advance, completion, information and change notification.

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