Electronic Data Interchange (EDI) provides the technology needed for health care providers to offer a better service. Electronic data exchange offers faster, more efficient and a cost-effective claim submission system for doctors.
EDI involves computer-to-computer transfer of business-to-business operations and the sharing of information (in this case Medicare claims) between providers that can send and receive healthcare transactions.
Healthcare EDI came as a result of the Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA, which mandated that all healthcare data transmissions must adhere to HIPAA standards and systems as well as accept and implement EDI for healthcare business processes.
These days, the driving force of HIPAA and EDI in healthcare is simplification. Implementation of technology is seen as the solution to meet consumer demands for more efficient healthcare services but also to standardize how health care facilities communicate, exchange data, and do claims electronically.
Thanks to the HIPAA EDI 837 Health Care Claim, which is the standard to send in claims, healthcare providers are permitted to submit claims electronically. Part of the HIPAA claim standard is the fact that the entire electronic data interchange process is to be done by computer only, from one computer system to another without human intervention. The benefit derived from using this standard is that it can improve the quality of healthcare delivery, as well as reduce the amount of phone calls and administration costs to get information on claims back to the requester.
Filing claims is made much easier for doctors, using a computer with software that meets electronic filing requirements as established by the HIPAA. EDI does help doctors file Medicare claims fast, inexpensively, and safely.
The adoption of EDI in healthcare has reduced overhead and administrative costs, and has eliminated the need for paper claim submission. EDI has not only provided information on a patients’ claim without delay, but has also been able to make available the status of a claim at a moment’s notice. Furthermore, EDI has sped up transaction and processing time for claims and has reduced the time to make and resolve claim changes and adjustments.
Those that need to file a Medicare claim can turn to the Centers for Medicare & Medicaid Services (CMSs) processing manual, chapter 24, which covers EDI filing procedures, or visit CMS.org and the EDI Transactions section of the website for further information.
Another helpful source can be found at the Washington Publishing Company website, http://www.wpc-edi.com/, which has guides and EDI schemas for HIPAA compliance, as well as a list of the health care codes of the approved American National Standards Institute (ANSI) ASCX12 transaction set numbers adopted under HIPAA standards.
X12 270/271, for example, provides eligibility transaction of CMS’s Medicare Fee-for-Service (FFS) Claims Processing for providers/submitters. Furthermore, for more HIPAA EDI knowledge, be sure to look over the other transaction sets, such as for Inquiry/Response (HIPAA EDI 270, 271), to know how they are implemented as well.