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EDI Transactions Sets

EDI Transaction set is format established to meet HIPAA requirements for electronic submission of Healthcare claim information.

EDI stands for “Electronic Data Interchange.” to exchange information – or data – electronically between two organizations Health Insurance Company and Health Service Providers (PCPs/Hospitals)  Technically, EDI is a set of standards which is defined in common formats for the information so it can be exchanged between the organizations.

In other words information exchange with paper have been replaced with an invisible, electronic flow of formatted data.  EDI has replaced paper forms of many documents, including invoices, bills of lading, advance shipping notifications, student transcripts, healthcare claims and many others.

Please find the EDI Transactions which are useful for Business Analysts.

834 Transaction Set:

The EDI 834 transaction set represents a Benefit Enrollment and Maintenance document for the electronic exchange of member enrollment information, including benefits, plan subscription and employee demographic information.

The 834 transaction may be used for any of the following functions relative to health plans:

  • New enrollments
  • Changes in a member’s enrollment
  • Reinstatement of a member’s enrollment
  • Disenrollment of members (i.e., termination of plan membership)

The information is submitted, typically by the employer, to healthcare payer organizations who are responsible for payment of health claims and administering insurance and/or benefits. This may include insurance companies, healthcare professional organizations such as HMOs or PPOs, government agencies such as Medicare and Medicaid.

A typical 834 document may include the following information:

  • Subscriber name and identification
  • Plan network identification
  • Subscriber eligibility and/or benefit information
  • Product/service identification

The recipient of an 834 transaction must respond with a 999 Implementation Acknowledgement, which confirms that the file was received and provides feedback on the acceptance of the document.

837 Transaction Set:

The claim information included amounts to the following,  care encounter between patient and provider:

  • A description of the patient
  • The patient’s condition for which treatment was provided
  • The services provided
  • The cost of the treatment

This transaction set is sent by the providers to payers (Health Insurance Company), These transactions may be sent either directly or indirectly via Electronic way. Health insurers and other payers send their payments and coordination of benefits information back to providers via the EDI 835 transaction set.

The EDI 835 transaction set is called Health Care Claim Payment and Remittance Advice. It has been specified by HIPAA 5010 requirements for the electronic transmission of healthcare payment and benefit information. 

835 Transaction Set:

The 835 is used primarily by Healthcare insurance companies to make payments to healthcare providers (such as PCPs/Hospitals) , to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

  • What charges were paid, reduced or denied
  • Whether there was a deductible, co-insurance, co-pay, etc.
  • Any bundling or splitting of claims or line items
  • How the payment was made, such as through a clearinghouse

835 is important to healthcare providers, to track what payments were received for services they provided and billed.

278 Transaction Set:

The EDI 278 transaction set is called Health Care Services Review Information. A healthcare provider, such as a hospital, will send a 278 transaction to request an authorization from a payer, such as an insurance company. The hospital is asking the insurance company to review proposed healthcare services to be provided to a given patient, in order to obtain an authorization for these services.

  • The 278 transaction can be used to submit information in the following categories:
  • Advance notification – for scheduled inpatient, specialty care or other services
  • Completion notification – for patient arrival to or discharge from a facility
  • Information copy – for any health services review information sent to service providers
  • Change notification – for reporting changes to previously sent information

A 278 may relate to services to be administered by the healthcare service provider, or for referring an individual to another provider. The transaction may also be used by the payer to respond to this request for an authorization. Thus, the 278 can be used either as a one-way transaction, or as a two-way “inquiry/response” type of transaction. 278 transaction typically contain healthcare related data, such as patient, diagnosis or treatment information. 

270 Transaction Set:

The EDI 270 Health Care Eligibility/Benefit Inquiry transaction set is used to request information from a healthcare insurance plan about a policy’s coverages, typically in relation to a particular plan subscriber.

This transaction is typically sent by healthcare service providers, such as hospitals or medical facilities, and sent to insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy.

The 270 transaction is used for inquiries about what services are covered for particular patients (policy subscribers or their dependents), including required copay or coinsurance. It may be used to inquire about general information on coverage and benefits. It may also be used for questions about the coverage of specific benefits for a given plan, such as wheelchair rental, diagnostic lab services, physical therapy services, etc.

The 270 document typically includes the following:

  • Details of the sender of the inquiry (name and contact information of the information receiver)
  • Name of the recipient of the inquiry (the information source)
  • Details of the plan subscriber about to the inquiry is referring
  • Description of eligibility or benefit information requested

The 270 transaction is used in conjunction with the EDI 271 transaction. The 271 is the Health Care Eligibility/Benefit Response and is used to transmit the information requested in a 270. 

271 Transaction Set: 

The EDI 271 Health Care Eligibility/Benefit Response transaction set is used to provide information about healthcare policy coverages relative to a specific subscriber or the subscriber’s dependent seeking medical services. It is sent in response to a 270 inquiry transaction.

This transaction is typically sent by insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy. It is sent to healthcare service providers, such as hospitals or medical clinics that inquire to ascertain whether and to what extent a patient is covered for certain services.

The 271 document typically includes the following:

  • Details of the sender of the inquiry (name and contact information of the information receiver)
  • Name of the recipient of the inquiry (the information source)
  • Details of the plan subscriber about to the inquiry is referring
  • Description of eligibility or benefit information requested

Service providers such as PCPS/Hospitals can submit the inquiry to multiple insurance providers and will receive information in the same standardized 271 response format.

Use of the 270 and 271 transactions also allows healthcare service providers to remain in compliance with HIPAA standards.

 

 

Source: For more information on EDI please click on the this link EDI Source