Sunday, 11 August 2013

EDI Transactions

The HIPAA transactions and code set standards are rules that standardize the electronic exchange of health-related administrative information, such as claims forms. The rules are based on electronic data interchange (EDI) standards, which allow for the exchange of information from computer-to-computer without human involvement.

A "transaction" is an electronic business document. Under HIPAA, a handful of standardized transactions will replace hundreds of proprietary, non-standard transactions currently in use. For example, the HCFA 1500 claims form/file will be replaced by the X12 837 claim/encounter transaction. Each of the HIPAA standard transactions has a name, a number, and a business or administrative use. Those of importance in a medical practice are listed in the table below.

Transaction Number Business use
Claim/encounter X12 837 For submitting claim to health plan, insurer, or other payer
Eligibility inquiry and response X12 270 and 271 For inquiring of a health plan the status of a patient.s eligibility for benefits and details regarding the types of services covered, and for receiving information in response from the health plan or payer.
Claim status inquiry and response X12 276 and 277 For inquiring about and monitoring outstanding claims (where is the claim? Why haven.t you paid us?) and for receiving information in response from the health plan or payer. Claims status codes are now standardized for all payers.
Referrals and prior authorizations X12 278 For obtaining referrals and authorizations accurately and quickly, and for receiving prior authorization responses from the payer or utilization management organization (UMO) used by a payer.
Health care payment and remittance advice X12 835 For replacing paper EOB/EOPs and explaining all adjustment data from payers. Also, permits auto-posting of payments to accounts receivable system.
Health claims attachments (proposed) X12 275 For sending detailed clinical information in support of claims, in response to payment denials, and other similar uses.

How EDI Works
Doctor diagnosis the patient and provide the treatment for the identified disease. Billing Team prepare the bill(claim) and the claim is transmitted into an EDI Document format called as 837 Health care claim. Then the EDI 837 Document securely transmitted to the insurance company via clearing house.

Then the Insurance company processes the claim which comes in the electronic format and provide the necessary reimbursement for the provider for the treatment given to the patient.

Why You Need EDI – the Benefits
  • Lower costs
  • Higher efficiency
  • Improved accuracy
  • Enhanced security
  • Greater management information
Interest to see some sample EDI Documents. Please check here.

837 Professional

Professional billing is responsible for the billing of claims generated for work performed by physicians, suppliers and other non-institutional providers for both outpatient and inpatient services. Professional charges are billed on a CMS-1500 form. The electronic version of the CMS-1500 is called the 837-P, the P standing for the professional format.

837 Institutional
Institutional billing is responsible for the billing of claims generated for work performed by hospitals and skilled nursing facilities. Institutional charges are billed on a UB-04.

Both sets of 837 specifications are same. The only differences would be claim specific data that pertains to a single transaction. All three transactions contain ISA, GS and ST segments but some data and qualifying codes are specific to the type of 837. Another way to quickly identify which type of 837 is being encountered is by the codes sent in the GS-08 or in the ST-03. Professionals use a 005010X222, Institutional uses a 005010X223 and Dental uses a 005010X224.

For 837 Institutional sample, please check here


Questions or feedback are always welcome. You can email me at 


  1. Hello, the whole thing is going fine here and ofcourse every one is sharing data, that’s in fact fine, keep up writing. I am very glad and lucky my self to visit this great blog. Thanks for sharing this.

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  2. Thanks for providing such useful information about edi. if you want to know more about electronic data interchange or want edi solution then you can visit below...


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