EDI 837 Transaction Set for Healthcare Claim Information

The Healthcare Insurance Portability and Accountability Act, better known as, HIPAA, was set in place in 1996 to protect patient’s private information as well as establish rules and requirements to stop fraud and waste in the industry.

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About The Author
Nitin Nijhawan, CDOicon

With a digital transformation taking place across the globe, the healthcare field, in particular, has been working to take their documentation online. To make it possible for this data to become computerized, a technology known as Electronic Data Interchange or "EDI" has been introduced. This technology uses “data sets” to ensure the electronic submission of claim information meets HIPAA requirements and has become a critical tool for any business in the medical and healthcare field today.
EDI offers a structured way for facilities and insurance companies to transmit data between computer systems using established message formats and standards.
Depending on the type of provider and the patient/care relationship, rules have also since been set in place to strengthen protections for privacy at every stage of interaction and payment.
In March 2012, the revised version 5010 of the HIPAA EDI standards was released. Within this standard are transaction and code sets that make it possible to identify the type of transaction and data being transmitted. Some of the most common include 837 for medical claims, 820 for premium payments, 834 for benefits, and many others.
More examples of EDI transaction codes include:

  • X12 837 – for claim/encounter transactions
  • X12 270 and 271 for eligibility inquiries and responses
  • X12 276 and 277 for claim status inquiries and responses
  • X12 278 for referrals and prior authorization transactions
  • X12 835 for healthcare payment and remittance information
  • X12 275 for health claims attachments

What is EDI 837

In this post, we’ll talk specifically about HIPAA EDI 837 which protects data related to healthcare claim billing. This transaction code is further divided into 3 categories: 837P for professionals, 837I for institutions and 837D for dental practices to use. To remain compliant, information must be created and then submitted by these establishments in a very specific format. Since the information that passes from computer to computer (via modem, FTP, e-mail or HTTP) contains sensitive health-related information such as medical history, claim forms, referrals, authorizations, and more, it is vital that it remains secure throughout the process.

How it Works

As documents are traded electronically between providers, insurance companies and clearinghouses, the information is translated into computer language. This EDI transaction/file looks much like a page with numbers and codes that once transmitted and downloaded on the recipients’ end, is decoded to again display in a readable format. To make it easier and faster to process the information, the transactions are each assigned specific codes that separate and categorize the type of information contained.
Manually building compliant documents to send electronically isn’t only time consuming, it also leaves room for potential errors and creates an unnecessary and lengthy process. However, remaining compliant with HIPAA regulations is the most critical task for organizations. To do so, they rely on HIPAA EDI compliant software or the expertise of a company that builds software solutions to meet the stringent requirements of their industry.
Using technology, the necessary data is automatically extracted from the computer, sent to an EDI translator which handles the work of creating the coded script to be sent and is then sent out. This speeds up processing time while also avoiding risks.
VLink has introduced SIMPLYEDI to help business users easily search for, view, edit and validate complex EDI files without any technical knowledge required- minimizing downtime and interruptions caused by inefficient EDI processes.
To make this possible, the tool has been designed with an intuitive dashboard so its easy to see if files have failed and where, and since it was designed in an open and extensible framework, can be easily configured to support many more EDI file formats used in industries even beyond healthcare.

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