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EDI Standards

According to the HIPAA EDI rule, a "transaction" is the exchange of information between two parties to carry out financial or administrative activities related to health care.

HIPAA identifies certain transactions for which there is a mandatory "standard" format and data content, which cannot be changed or altered by covered entities when conducting any of those transactions.

The Department of Health and Human Services has adopted "Implementation Guides" that outline each of the transaction standards. These Guides can be found on the Washington Publishing Company website.

The HIPAA EDI transaction standards are referred to by both a name and a numerical identifier. For example the transaction that is used to support the electronic payment of premiums is often referred to as the 820 transaction standard.

The HIPAA EDI transaction standards that impact our covered products are as follows:

  • 834 Enrollment/disenrollment
  • 270 Eligibility inquiry
  • 837 Claim encounter
  • 276 Claim status inquiry
  • 835 Remittance advice EOB
  • 820 Premium payment
  • 271 Eligibility response
  • 837 COB Coordination of benefits
  • 277 Claim status response

Please click this link for more information on the HIPAA EDI transaction standards that impacts our covered products.