HIPAA EDI Transactions

EDI Provider Communication

1. EDI 270 Eligibility, Coverage or Benefit Inquiry:

• Communication: Providers (Hospitals, Medical facilities etc.) to Payers
• This 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 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.
• Used for inquiries about what services are covered for particular patients (policy subscribers or their dependents), including required copay or coinsurance and other coverage benefits
• It contains following details: 
• 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

2. EDI 271 Eligibility, Coverage or Benefit Information/Response:

• Communication: Payer to Providers
• It is sent in response to a 270 inquiry transaction.
• This transaction set is used to provide information about healthcare policy coverages relative to a specific subscriber or the subscriber’s dependent seeking medical services. 
• This transaction is sent by insurance companies or 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: 
• 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

3. EDI 278 Health Care Services Review /Utilization/ Pre authorization/provider referral Information:

• Communication: Providers (Hospitals, Medical facilities etc.) to Payers
• 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 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

4. EDI 837 Health Care Claim /Encounter:

• Communication: Provider to Payer
• Used for electronic submission of healthcare claim
• The claim information included amounts to the following, for a single 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

837 transaction set into three groups, as follows: 

• 837P for professionals: 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.
• 837I for institutions: Institutional billing is responsible for the billing of claims generated for work performed by hospitals, skilled nursing facilities, and other institutions for outpatient and inpatient services including the use of equipment and supplies, laboratory services, radiology services, and other charges. 
• 837D for dental practices: Responsible for the billing of claims generated for dental treatments

5. EDI 276 Health Care Claim Status Request:

• Communication: Provider to Payer
• It is used by healthcare providers to verify the status of a claim submitted previously to a payer, such as an insurance company, HMO, government agency like Medicare or Medicaid, etc.
• It includes: 
• Provider identification
• Patient identification
• Subscriber information
• Date(s) of service(s)
• Charges

6. EDI 277 Health Care Information Status Notification/Response:

• Communication: Payer to Provider
• This transaction set is used by healthcare payers (insurance companies, Medicare, etc.) to report on the status of claims (837 transactions) previously submitted by providers.
• This can be used in one of the following three ways: 
• A 277 transaction may be sent in response to a previously received EDI 276 Claim Status Inquiry
• A payer may use a 277 to request additional information about a submitted claim (without a 276)
• A payer may provide claim status information to a provider using the 277, without receiving a 276

This 277 transaction indicates where the claim is in process, either as Pending or Finalized.

• If finalized, the transaction indicates the disposition of the claim – rejected, denied, approved for payment or paid.
• If the claim was approved or paid, payment information may also be provided in the 277, such as method, date, amount, etc.
• If the claim has been denied or rejected, the transaction may include an explanation, such as if the patient is not eligible.

7. EDI 835 Health Care Claim Payment and Remittance Advice: (837 response)

• Communication: Payer to Provider
• The 835 is used by Healthcare insurance plans to make payments to healthcare providers, 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.

Other EDI Transactions:

8. EDI 834 - Benefit Enrollment and Maintenance: 

• Communication: CMS to Payer for enrollment and Payer to CMS for reconciliation
• Used by employers, government agencies or insurance agencies, to enroll members in a healthcare benefit plan. (CMS sends these details to payer)
• The 834 has been specified by HIPAA 5010 standards for the electronic exchange of member enrollment 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)
• 834 document may include the following information: 
• Subscriber name and identification
• Plan network identification
• Subscriber eligibility and/or benefit information
• Product/service identification
• Agent, Provider associated to member policy

9. EDI 820 Payment Order/Remittance Advice:

• Communication: CMS to Payer and CMS sends HIX 820 to state based market place
• Contains electronic transfer of funds for insurance premiums. 
• The actual funds transfer is often coordinated through the Automated Clearinghouse (ACH) system, and an 820 may be effectively wrapped in an ACH banking transaction.
• 820 Transaction contains below details:
• Includes payer and payee identification, bank and account IDs, invoice number(s), adjustments from an invoice, billed and paid amounts. 
• This information allows the suppliers and health plans to reconcile payments they receive against invoices they have issued.

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