Question 1

What is X12 EDI?

Accepted Answer

X12 EDI is a data format based on ASC X12 standards developed by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). It is used to electronically exchange business documents in specified formats between two or more trading partners. X12 EDI releases are known by a version number. Learn more about PilotFish’s Interface Engine with exclusive X12 EDI tools to process all your transactions.

Question 2

What is the X12 format?

Accepted Answer

X12 is a standard for Electronic Data Interchange (EDI) developed and maintained by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). The X12 standard governs the exchange of business documents (e.g., purchase orders, invoices, healthcare claims, etc.) in standard electronic formats between trading partners – for example, EDI 837 Health Care Claim Transaction Set. PilotFish provides broad support for all X12 standards and HIPAA transactions.

Question 3

What is EDI?

Accepted Answer

Electronic data interchange (EDI) is the structured exchange of business documents between organizations by electronic means based on widely accepted and agreed to standards. EDI standards govern electronic data exchange in finance, government, healthcare, insurance, retail, transportation and more.

Question 4

What does EDI stand for?

Accepted Answer

EDI is an abbreviation and shorthand for Electronic Data Interchange, a structured way to transmit data between computer systems using established message formats and standards. The businesses or organizations exchanging data are called trading partners in EDI terminology.

Question 5

What is an EDI transaction?

Accepted Answer

An EDI transaction set or EDI transaction is a group of one or more data segments representing a business document exchanged between trading partners to carry out financial or administrative activities – e.g., EDI 820 Payment/Remittance, EDI 999 Acknowledgment, EDI 834 Benefit Enrollment/Maintenance. The standard prescribes the formats, character sets and data elements used. View the format &amp; description of the most common X12 EDI transactions.

Question 6

What is EDI capable?

Accepted Answer

EDI capable is the ability to send and receive electronic business documents in a specific format based on established standards. It also refers to having in place an EDI solution that can streamline business workflows and onboard partners quickly. EDI capable can further encompass strategy and solutions that deliver efficiencies and high productivity. Learn more about PilotFish’s EDI Capable Integration Engine with built-in X12 EDI tools.

Question 7

What is EDI parsing?

Accepted Answer

EDI parsing is the process of matching the incoming data with a defined schema to identify, flag and/or fix data transformation issues. EDI parsing errors include data type mismatches, invalid records, incorrect values, incorrect segment and element usages, etc. While X12 EDI formats are based on the published standards – in the real world, deviations and differences between X12 EDI transactions are the norm. Learn more about PilotFish’s built-in EDI parser.

Question 8

What is EDI mapping?

Accepted Answer

EDI mapping is the process through which EDI data is translated and transformed into a format more easily used or required by a trading partner or both. Data mapping is the capability to map source data fields to related target data fields in converting EDI to other formats such as XML, Excel, databases, JSON or other EDI formats. Learn more about EDI mapping with PilotFish.

Question 9

Which is better EDI or API?

Accepted Answer

EDI (Electronic Data Interchange) is used for the transfer of structured data, by agreed message standards, from one computer system to another without human intervention. EDI is one of the safest ways to transfer data. Companies can exchange large amounts of EDI data simultaneously as well as transfer huge volumes via a single transfer. An API (Application Programming Interface) is a connection between computers or between computer programs via calls, working on a request-response basis.

Question 10

Is API better than EDI?

Accepted Answer

Application Programming Interfaces (APIs) work on a request-response basis. They are not intended for transactional interfaces or standards-based integration. While very beneficial in many integration scenarios, creating APIs and integrating with them also requires programming expertise. For most backend internal system integrations, APIs are more costly to develop and maintain. Increasingly, trading partners are using a mix of APIs and EDI.

Question 11

What is healthcare EDI?

Accepted Answer

Most commonly, healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) rules requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status inquiries, remittance advice and benefit enrollment.

Question 12

What is HIPAA EDI?

Accepted Answer

In the electronic exchange of financial and administrative healthcare transactions, the Health Insurance Portability and Accountability Act (HIPAA) requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/ authorization and premium payment to health insurance plan.

Question 13

What are healthcare EDI transactions?

Accepted Answer

In EDI, a single business document is called a “transaction set” or “message.” HIPAA requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for structured message exchange. Electronic transactions covered include healthcare claims, claims status and remittance advice, eligibility verifications and responses, referrals and authorizations, and coordination of benefits.

Question 14

How does EDI work in healthcare?

Accepted Answer

Healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status, remittance advice and benefit enrollment.

Question 15

What is an EDI claim?

Accepted Answer

HIPAA X12 EDI transaction sets are structured messages standardized and required for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/authorization and premium payment to health insurance plans by all health plans, healthcare clearinghouses and healthcare providers.

Question 16

How does EDI work in medical billing?

Accepted Answer

EDI allows entities within the healthcare ecosystem to exchange medical, billing and other information quickly and cost effectively. Medical billing involves timely exchange of specific HIPAA EDI documents (claims, remittance advice, eligibility inquiry, claim status inquiry), accurate medical coding, and secure information exchange to and from provider and payer entities as well as third-party vendors and clearinghouses.

Question 17

What are some benefits of using EDI for healthcare data exchange?

Accepted Answer

EDI can help reduce costs, improve accuracy and efficiency, enhance patient privacy and security, and improve overall healthcare quality and outcomes.

Question 18

What are some emerging trends in EDI healthcare?

Accepted Answer

Cloud-based EDI solutions, blockchain technology, and AI driven analytics are some emerging trends in EDI healthcare parsing and validation.

Question 19

What is EDI healthcare data conversion, and how does it work?

Accepted Answer

EDI healthcare data conversion is the process of converting healthcare data into EDI format to enable secure transmission and integration into other systems. It involves mapping data elements from the source format to EDI standards, such as X12.

Question 20

What are the benefits of using EDI in healthcare data integration?

Accepted Answer

EDI enables secure and real-time exchange of healthcare data between providers, payers, and patients. It helps reduce errors, streamline workflows, and improve data accuracy and patient care.

Question 21

What is EDI 834 data conversion, and why is it important for technical users interested in PilotFish’s integration tools?

Accepted Answer

Electronic Data Interchange (EDI) 834 data conversion is the process of translating data between different formats, often involving transforming data from CSV, XLS/Excel, or TXT to the EDI 834 format used for Benefit Enrollment and Maintenance. For technical users considering PilotFish’s integration tools, this process is vital as it enables seamless data communication between systems, facilitating efficient data integration and management. Watch our EDI 834 Transformation Video.

Question 22

What is the role of EDI in healthcare supply chain management?

Accepted Answer

EDI enables healthcare organizations to automate supply chain management processes, such as inventory tracking, order processing, and invoicing. It helps reduce manual errors, improve efficiency, and increase supply chain visibility.

Question 23

What are the key considerations for selecting an EDI software provider for healthcare data conversion and integration?

Accepted Answer

Key considerations include expertise in healthcare EDI, knowledge of industry regulations, reliability and scalability of the platform and support and training services.

Question 24

How can healthcare organizations integrate EDI with their existing EHR and practice management systems?

Accepted Answer

Healthcare organizations can integrate EDI by using middleware solutions that enable seamless data exchange between different systems, or by using APIs that enable real-time data transfer between systems. See EHR Integration Solutions.

Question 25

What are the key benefits of using EDI for healthcare data conversion and integration?

Accepted Answer

Key benefits include improved data accuracy and timeliness, reduced costs and errors, increased efficiency and productivity, enhanced patient care and outcomes, and compliance with industry regulations and standards.

Question 26

What are some common EDI healthcare transactions?

Accepted Answer

Claim submissions (EDI 837), remittance advice (EDI 835), eligibility verification (EDI 270/271), and prior authorization (EDI 278) are some common EDI healthcare transactions.

Question 27

What are the HIPAA X12 transaction sets?

Accepted Answer

The key X12 EDI transaction sets specified by HIPAA include: EDI 270 Healthcare Eligibility/Benefit Inquiry; EDI 271 Healthcare Eligibility/Benefit Response; EDI 275 Patient Information; EDI 276 Healthcare Claim Status Request
EDI 277 Healthcare Claim Status Notification; EDI 277 Healthcare Claim Acknowledgment; EDI 278 Healthcare Service Review Information; EDI 820 Payroll Deducted and other group Premium Payment for Insurance Products
EDI 824 Application Advice; EDI 834 Benefit Enrollment and Maintenance; EDI 835 Healthcare Claim Payment/Advice; EDI 837 Healthcare Claim and Maintenance; EDI 997 Functional Acknowledgment for Healthcare Insurance; EDI 999 Functional Acknowledgement; EDI TA1 Interchange Acknowledgment

Question 28

What X12 EDI supply chain transactions are used in healthcare?

Accepted Answer

Common Types of X12 EDI Supply Chain Transactions include: EDI 180 Return Notification and Authorization; EDI 810 Invoice; EDI 820 Payment Order and Remittance Advice; EDI 824 Application Advice; EDI 832 Price/Sales Catalog; EDI 846 Inventory Inquiry and Advice; EDI 850 Purchase Order; EDI 855 Purchase Order Acknowledgment; EDI 860 Purchase Order Change; EDI 864 Text Message; EDI 997 Functional Acknowledgment
EDI TA1 Interchange Acknowledgment

Question 29

Does PilotFish support all X12 EDI 5010 healthcare transaction sets including 270/271, 275, 276/277, 277CA, 277P, 278, 820, 824, 834, 835, 837 I/P/D, 999?

Accepted Answer

Yes, PilotFish fully supports all the X12 EDI 5010 transaction sets.

Question 30

Where does the EDI 835 and EDI 837 data typically come from?

Accepted Answer

The EDI 835 and 837 data, essential in healthcare EDI (Electronic Data Interchange), usually originates from healthcare clearinghouses or practice management systems. The EDI 835 transaction covers healthcare claim payments, while the EDI 837 transaction involves claim submission. The data extraction process can vary based on the source system. For more details, see our EDI 837 demo video or read this HIE &amp; Claims Clearinghouse case study.

Question 31

What is EDI 270 Eligibility, Coverage of Benefit Inquiry?

Accepted Answer

The EDI 270 transaction set and format is used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or dependent under the subscriber’s policy. The transaction set may be used by all lines of insurance such as Health, Life, and Property and Casualty. For more detailed information see EDI 270 format and example.

Question 32

What is EDI 271 Eligibility, Coverage of Benefit Information?

Accepted Answer

The EDI 270 transaction set and format is used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as – insurers, sponsors, payors) to information receivers (such as – physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, co-insurance, co-pays, deductibles, exclusions and limitations. For more detailed information, see EDI 271 format and example or read this EDI 271 integration case study.

Question 33

What is EDI 275 Patient Information?

Accepted Answer

The EDI 275 transaction set is used to communicate individual patient information requests and patient information between separate health care entities in a variety of settings to be consistent with confidentiality and use requirements. Patient information consists of demographic, clinical, and other supporting data. The EDI 275 can be sent either solicited or unsolicited. The EDI 275 Patient Information is an EDI transaction designed to carry attachments. For more detailed information, see EDI 275 format and example.

Question 34

What is EDI 276 Healthcare Claim Status Request?

Accepted Answer

The EDI 276 transaction set is used by a provider, recipient of healthcare products or services, or their authorized agent to request the status of a healthcare claim or encounter from a healthcare payer. Note: EDI 276 does not replace the EDI 837 Healthcare Claim transaction set, but is intended for use after the receipt of a claim or encounter information. Such a request may occur at the summary or service line detail level. For more detailed information, see EDI 276 format and example.

Question 35

What is EDI 277 Healthcare Claim Status Notification?

Accepted Answer

The EDI 277 is used by a healthcare payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a healthcare claim or encounter or to request additional information from the provider regarding a healthcare claim or encounter, healthcare services review, or transactions related to the provisions of healthcare. The notification may be solicited or unsolicited. EDI 277 does not replace the Healthcare Claim Payment/Advice Transaction Set (EDI 835). It is not used for account payment posting. The notification may be at a summary or service line detail level. For more detailed information, see EDI 277 format and example.

Question 36

What is EDI 277 Healthcare Claim Status Response?

Accepted Answer

The EDI 277 is Acknowledgement/Returned as Unprocessable Claim-The claim/encounter has been rejected and has not been entered into the adjudication system. The EDI 277 transaction set has been specified by HIPAA for the submission of claim status information to respond to a previously received EDI 276 Claim Status Inquiry, to request that a payer provide additional information about a submitted claim (no 276 involved), or for a payer to provide claim status information to a provider via the EDI 277, without having received a 276.

Question 37

What is EDI 277CA Healthcare Claim Acknowledgment?

Accepted Answer

The EDI 277CA Healthcare Claim Acknowledgment provides a claim level acknowledgment of all claims received in the payer’s pre-processing system before submitting claims into an adjudication system. It is created in receipt of an incoming EDI 837 5010 claim submission transaction. The 277CA offers a common report interface to payers and providers. Most clearinghouses and payers now use the 277CA as their standardized reporting mechanism for 5010. The 277CA reports on whether pre-adjudication validation found the claims acceptable for adjudication. There are no Category Codes signifying ‘accepted with warning’. The 277CA cannot report syntax issues. The EDI 277CA transaction is not required by HIPAA. For more information, refer to the TR3 Implementation Guide (Technical Report Type 3).

Question 38

What is EDI 278 Healthcare Services Review Request?

Accepted Answer

The EDI 278 transaction set can be used to transmit healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

Question 39

What is EDI 278 Healthcare Services Review Response to a Request?

Accepted Answer

The EDI 278 transaction set can be used to responses to requests for healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

Question 40

What is EDI 820 Payment Order/Remittance Advice?

Accepted Answer

The EDI 820 transaction set can be used to make a payment, send remittance advice, or make a payment and send remittance advice. This transaction set can be an order to a financial institution to make a payment to a payee. It can also be a remittance advice identifying the detail needed to perform cash application to the payee’s accounts receivable system. The remittance advice can go directly from payer to payee, through a financial institution, or through a third-party agent. For more detailed information, see EDI 820 format and example or read this EDI 820 integration case study.

Question 41

What is EDI 824 Application Advice?

Accepted Answer

The EDI 824 acknowledgment is used as a means of communicating errors in a previous transaction. The EDI 824 report allows the trading partner who sent the original transaction to identify, correct and resubmit that transaction. In healthcare applications, the optional EDI 824 transaction meets HIPAA 5010 requirements for non-claims (EDI 276, 270 and 278) transactions. In practice, EDI 824 is used or even required as an acknowledgment to EDI 837 Claims as well. The 824 acknowledgment also is used report the success of failure of an EDI 275 attachment transaction. The 824 can embed an HL7 report on the acceptance of the HL7 or identifying specific HL7 syntax errors. For more detailed information, see EDI 824 format and example.

Question 42

What is EDI compliance?

Accepted Answer

EDI compliance refers to the adherence to the specific EDI standards and requirements set forth by a trading partner or industry. Being EDI compliant means that a business can accurately and consistently exchange EDI documents in the required format, ensuring smooth transactions. Compliance often involves meeting specific protocols, data elements, and transaction sets. Discover how PilotFish’s Integration Engine ensures full EDI compliance with all major standards.

Question 43

What are EDI standards?

Accepted Answer

EDI standards are predefined formats for exchanging business documents electronically. These standards ensure that the data exchanged between trading partners is understood and processed consistently. Common EDI standards include ANSI X12, EDIFACT, and TRADACOMS. Each standard specifies the structure, data elements, and syntax rules. PilotFish supports a wide range of EDI standards, making it easy to integrate with any trading partner.

Question 44

What is an EDI segment?

Accepted Answer

An EDI segment is a logical grouping of related data elements within an EDI message. Each segment represents a specific piece of information, such as an address or an item description. Segments are the building blocks of EDI transactions, organized in a defined sequence to form a complete message. Learn more about how PilotFish handles EDI segments and ensures accurate data exchange.

Question 45

How does EDI improve business processes?

Accepted Answer

EDI improves business processes by automating the exchange of critical business documents, reducing manual data entry, and minimizing errors. This leads to faster transaction processing, improved accuracy, and enhanced operational efficiency. Businesses can streamline their supply chain, reduce costs, and improve relationships with trading partners. PilotFish’s EDI solutions help businesses leverage these benefits to the fullest.

Question 46

What is an EDI envelope?

Accepted Answer

An EDI envelope is a container that holds a set of EDI documents to be transmitted between trading partners. It includes headers and trailers that provide information about the sender, receiver, and the type of documents enclosed. The envelope ensures that the data is correctly identified and routed upon receipt. Explore how PilotFish’s Integration Engine manages EDI envelopes to ensure secure and accurate data transmission.

Question 47

What is EDI translation?

Accepted Answer

EDI translation is the process of converting EDI data from a standard format into a format that can be easily used by internal systems or applications. This involves parsing the EDI messages and transforming the data into formats like XML, JSON, or proprietary formats. PilotFish offers powerful EDI translation tools to facilitate seamless data integration and processing.

Question 48

What is an EDI gateway?

Accepted Answer

An EDI gateway is a service that facilitates the transmission and reception of EDI messages between trading partners. It acts as a bridge, ensuring that EDI transactions are securely and efficiently exchanged. EDI gateways handle communication protocols, encryption, and message validation. Learn how PilotFish’s EDI gateway solutions can streamline your EDI communications.

Question 49

What are EDI trading partners?

Accepted Answer

EDI trading partners are the entities (businesses or organizations) that exchange EDI documents with each other. Each partner in the EDI network must adhere to agreed-upon standards and protocols to ensure successful data exchange. Establishing reliable EDI trading partner relationships is crucial for smooth operations. Discover how PilotFish helps manage and onboard new EDI trading partners effortlessly.

Question 50

What is EDI validation?

Accepted Answer

EDI validation is the process of checking EDI documents for accuracy and compliance with established standards before they are sent or received. This includes verifying data integrity, ensuring all required segments and elements are present, and checking for any format errors. EDI validation helps prevent errors and disruptions in the data exchange process. PilotFish provides robust EDI validation features to ensure data quality and compliance.

Question 51

How does EDI improve patient care in healthcare?

Accepted Answer

EDI improves patient care by ensuring accurate and timely exchange of health information between providers, payers, and other stakeholders. This leads to better-informed decision-making, reduced administrative burden, and quicker response times, all of which enhance patient outcomes.

Question 52

What are the security measures in place for EDI transactions in healthcare?

Accepted Answer

EDI transactions in healthcare are protected by several security measures, including encryption, secure networks, and compliance with HIPAA regulations. These measures ensure that sensitive patient information is transmitted securely and is accessible only to authorized parties.

Question 53

How do EDI standards like X12 and HL7 differ in healthcare?

Accepted Answer

X12 and HL7 are both standards for electronic data interchange in healthcare, but they serve different purposes. X12 is primarily used for financial and administrative transactions such as claims and eligibility, while HL7 is used for clinical and medical data exchange. Both standards ensure interoperability and data integrity across systems.

Question 54

What is the role of EDI in healthcare analytics?

Accepted Answer

EDI plays a crucial role in healthcare analytics by providing structured and standardized data that can be easily aggregated and analyzed. This data can be used to identify trends, measure performance, and make data-driven decisions to improve healthcare delivery and patient outcomes.

Question 55

How can PilotFish’s EDI solutions help with compliance in healthcare?

Accepted Answer

PilotFish’s EDI solutions help healthcare organizations maintain compliance with industry standards and regulations such as HIPAA. By providing robust data validation, secure transmission, and comprehensive auditing capabilities, PilotFish ensures that healthcare data exchanges meet all regulatory requirements.

Question 56

What are common challenges in implementing EDI in healthcare, and how can they be overcome?

Accepted Answer

Common challenges include system integration, data mapping, and compliance with standards. These can be overcome by using middleware solutions like PilotFish, which provide tools for seamless integration, comprehensive data transformation capabilities, and built-in compliance checks.

Question 57

How does EDI support value-based care initiatives in healthcare?

Accepted Answer

EDI supports value-based care by facilitating the exchange of data necessary for performance measurement, patient engagement, and care coordination. Accurate and timely data exchange helps providers focus on quality and outcomes, essential components of value-based care.

Question 58

What is the impact of EDI on healthcare revenue cycle management?

Accepted Answer

EDI streamlines revenue cycle management by automating claims processing, eligibility verification, and payment posting. This reduces manual errors, accelerates payment cycles, and improves cash flow for healthcare providers.

Question 59

How does PilotFish integrate EDI with emerging healthcare technologies like FHIR?

Accepted Answer

PilotFish integrates EDI with emerging technologies like FHIR by providing flexible and configurable interfaces that support various data formats and protocols. This enables seamless data exchange between traditional EDI systems and modern healthcare applications, enhancing interoperability and innovation.

Question 60

What role does EDI play in telehealth and remote patient monitoring?

Accepted Answer

EDI facilitates telehealth and remote patient monitoring by enabling the secure and efficient exchange of patient data between remote monitoring devices, healthcare providers, and payers. This ensures timely access to patient information, supporting effective remote care and monitoring.

Question 61

How does EDI 837 coordinate with EDI 835?

Accepted Answer

The EDI 837 transaction set is used for submitting healthcare claims, while the EDI 835 transaction set provides payment and remittance advice for those claims. The EDI 837 submits the initial claim, and the EDI 835 details the payment and any adjustments made. For more detailed information, see EDI 837 and EDI 835 formats and examples.

Question 62

How does EDI 820 Payment Order/Remittance Advice work in healthcare?

Accepted Answer

The EDI 820 transaction set is used to make payments and provide remittance advice. In healthcare, it is commonly used for premium payments to health insurance companies and for providing details on the payment and any adjustments made. For more detailed information, see EDI 820 format and example.

Question 63

What is the role of EDI 270/271 in healthcare?

Accepted Answer

The EDI 270 transaction set is used for healthcare eligibility inquiries, while the EDI 271 transaction set provides the response with eligibility and benefit information. These transactions help providers verify patient eligibility and coverage before providing services. For more detailed information, see EDI 270 and EDI 271 formats and examples.

Question 64

How can healthcare providers use EDI 276 and EDI 277?

Accepted Answer

The EDI 276 transaction set is used to request the status of a healthcare claim, and the EDI 277 transaction set provides the response with claim status information. These transactions help providers track the progress of submitted claims. For more detailed information, see EDI 276 and EDI 277 formats and examples.

Structured Data

X12 EDI FAQ

X12 EDI Frequently Asked Questions

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