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HIPAA EDI (Electronic Data Interchange)

Optimize transmission of important business documents with innovative EDI solutions that are HIPAA compliant.

HIPAA EDI (Electronic Data Interchange)

What Are HIPAA EDI Transactions?

HIPAA EDI is commonly used in the medical community to protect patient’s information and the records of healthcare facilities or hospitals.

HIPAA EDI transaction is a part of HIPAA EDI rule that involves electronic exchange of information between two or more parties to carry out financial or administrative activities in the healthcare sector. The transmission of electronic documents between patients, healthcare providers, and other involved parties is done through an EDI mode of communication, such as email, FTP, and HTTP. Communication that is not HIPAA EDI defined is used to classify electronic business documents.

Under the HIPAA EDI rule, the Department of Health and Human Services (HHS) adopts standard rules for the electronic exchange of healthcare data between covered entities and business associates. The transactions include claims status, payment & remittance advice, premium payment, enrollment & disenrollment, eligibility, coordination of benefits, and referrals & authorizations.

Transmission Specifications

As per the HIPAA EDI rule, when a computer system transmits data to another system, it is important for the sending entity to follow data transmission specifications. Also, the receiving party must adhere to these specifications. HIPAA EDI transactions require both parties to use the X12N EDI data transmission protocol. These protocols ask the covered entities to use specific data code sets. The current code set standard format is ASC X12 Version 5010, or HIPAA 5010.

HIPAA EDI Advantages

The primary benefit of the HIPAA electronic data interchange rule is security and accuracy while exchanging computer-processable healthcare data between medical professionals, institutions, and patients. The responding entity should also use the same format to ensure accuracy. Another advantage of HIPAA EDI is improved productivity, efficiency, and speed. With limited user input, there are fewer chances of errors which were quite common in manual transmissions.

What Are HIPAA EDI Code Sets?

Code sets refer to a shared list of codes that are commonly used to replace longer names or explanations. In HIPAA EDI healthcare transactions, medical code sets are widely used to quickly identify:

  • Treatments, procedures, and tests
  • Medical equipment and supplies
  • Medications
  • Diagnoses

Non-medical code sets are used in medical transactions to identify:

  • Organizational routing information
  • Claim payment adjustment information
  • Claim status information
  • ZIP code information

When healthcare providers use code sets in standard transactions, it streamlines the administrative process by reducing time to translate information into different formats.

Different healthcare activities use different code sets, including:

  • The code set for diagnoses (ICD-10-CM) is the CD-10 – International Classification of Diseases, 10th edition.
  • The code set for procedures (ICD-10-PCS) is the International Classification of Diseases, 10th edition.
  • The code set for outpatient services/procedures is CPT – Current Procedural Terminology.

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