Healthcare usage of Electronic Data Interchange

In this era of digitization, healthcare market is no exception. Organizing and sending out patient medical record information and health insurance repayment information between medical and dental entities has constantly been a complex process. Nevertheless, EDI execution has helped with in saving time, resources, and cash.

In addition, sometimes CMS and commercial payors also need medical necessity documentation for certain procedures. These supporting files maybe included together with the initial electronic claims submitted. This leads to fewer denial and rework demands which help both companies and payors. Few frequently used sets in Healthcare are listed below:

Eligibility, Coverage, or Benefit Inquiry and Response

The Healthcare Eligibility/Benefit Inquiry transaction set is sent by the doctor to the payer for requesting information from a healthcare insurance strategy about a policy’s protection, in relation to a specific plan customer.

Inquires have to do with what services are covered for a particular patient (either the policy holder or their dependents), this also includes the needed deductible, copay, and coinsurance related to the subscribed health plan or any other general information on protection and advantages. It might also be made use of for concerns about the protection of specific advantages for a provided plan, such as wheelchair rental, diagnostic lab services, physical therapy services, etc

Enrollment and Dis-enrollment in a Health Plan

The Enrollment and Dis-enrollment transaction is sent out by the subscriber (such as companies, unions, federal government agencies, or insurance coverage companies) to healthcare payer organizations for enrolling members in a healthcare benefit plan. The other functions relative to a healthcare strategy carried out by EDI can be adjustment, renewal, or termination of member’s enrollment.

Premium Payment

The Premium Payment deal set is sent by the customer to healthcare payer organizations to provide the EDI format for sending information related to payments. It is mostly used in conjunction with an electronic transfer of funds for payment of products, insurance coverage premiums, or other transactions. The real funds transfer is often coordinated through the Automated Clearinghouse (ACH) system. The ACH acts as mediator to forward assert information from the company to the payer.

The functions provided by EDI deal are listed below:

  • To offer guidelines to banks for making a payment to a payee
  • To communicate the information of a pending payment or adjustments
  • To provide premium payment information to medical insurance plans


Referral Certification and Authorization

The Referral Certifications and Authorizations transaction set is sent by the healthcare provider (such as a healthcare facility) to ask for a permission from a payer (such as an insurance coverage company). The healthcare facility asks the insurance coverage company to review proposed healthcare services in order to obtain a permission for the services to be provided to a patient.

Coordination of Benefits

The Coordination of Benefits transaction set is developed to fulfill the Health Insurance Portability and Accountability Act (HIPAA) requirements for the electronic submission of healthcare claim information by the health insurance company. It helps in figuring out if it must be the primary or secondary payer to represent the medical claims for a patient who has coverage from more than one health insurance policy.

The Healthcare Claim Status deal set is made use of by the healthcare providers to validate the status of a claim submitted previously to a payer, such as an insurance coverage company, HMO, government agency like Medicare or Medicaid, etc

Healthcare Claim Payment/Advice

The Healthcare Claim Payment/Advice deal set is used mainly by the healthcare insurance prepares making payments to doctor, to provide Explanations of Benefits (EOBs), or both. When a healthcare provider submits a Healthcare Claim, the insurance plan makes use of the EDI to explain the payment in detail.

Post a comment