EDI communications are the exchange of information from machine to machine, hence require less human intervention to even classify the most sensitive information.

EDI Basics: Understanding the HIPAA Document Standards

Numerous health care businesses face issues related to critical information security risks, such as data loss, misdirection, or obstructions.

In order to protect the client’s as well as their own information, HIPAA EDI document transaction set is the strengthening strategic standard created for the medical community to deal with these snags.

But, first, let’s learn about the standards furnished for EDI Document.

EDI Document Standards 

ANSI ASC X12

The ANSI is described as American National Standards Institute. The institute sanctioned the Accredited Standards Committee to develop standards for EDI business transactions.

The standard today is used by more than 300,000 companies globally for everyday seamless transactions. Today’s ANSI X12 is –

• Drawn up with concord to stakeholders
• Compatible with organization’s standards
• Compatible with many syntaxes
• Continuously evolving for continuous support

EANCOM 

The EANCOM is a standard that transfers the message in a logical sequence. These messages are further categorized in Master Data, Commercial Transactions, Report & Planning, and Transporter. The transaction sequence of EANCOM cover these functions:

1. A message to enable the trade transaction, such as purchase order, invoice, etc.
2. A message to guide transport services to carry goods.
3. A message to settle the trade transaction via the banking system.

EANCOM is a simple and sophisticated EDI standard for accurate message transfers that can be integrated with any industry.

VICS 

The abbreviated form of Voluntary Inter-industry commerce standard, VICS is a subset of ANSI ASC X12 standard.

VICS is usually used in retail industries, such as the general merchandise department across North America, and is also implemented by the grocery industry with both commercial/industrial standards.

The management body of VICS, GS1 has set standards to enable –

• Companies to have enlarged goods visibility in the supply chain.

• Follow the entire process of food delivered – from production to delivery.
• Easy access to the product’s information through mobile.

UN/EDIFACT

An electronic data interchange for administration, commerce, and transportation was established by the UN center for trade facilitation and electronic business.

This standard is mostly used in Europe that provides a standard set of syntax rules, which enable the provider to transfer messages inter-country and inter-industry.

SWIFT

Swift enables the provider to transmit the financial messages between banks and financial institutions securely.

Through a SWIFTNet infrastructure, documents are exchanged under FIN, InterAct, and FileAct encoders. The SWIFT is also known as Society of Worldwide Interbank Financial Telecommunications, which is split into areas that are –

• Securities

• Trading
• Payments
• Trade Services

RosettaNet

A documented standard based on XML is majorly used by semiconductor manufacturers, telecommunications, consumer electronics, and logistics companies.

The e-business language, ROsettaNet aligns business processes with supply chain partners globally through integrated frameworks.

The interactive framework where companies can interact and exchange information is Partner Interface Processes (PIPs).

A reference model, RosettaNet Technical Dictionary (RNTD) enables easy classification and understanding of the key characteristics of the goods, in the supply chain, used during interaction.

ODETTE 

Largely used in Europe, the Organization for Data Exchange (ODETTE) is the interest of the automotive industry. Tele Transmission builds recommendations as well as the right tools to treat the flow of goods, product data services, and business data across the industry value chain.

• ODETTE has its communication standards developed, OFTP and OFTP2.0 protocols that improve the processes and enhance competitiveness with time.
• MMOG/LE supply chain management capability assessment can balance with the demands of customers efficiently through Odette ID – unique identification code.

VDA

This EDI standard has been developed pertaining to the needs of the German automotive industry. The VDA built 30 messages to meet the needs of companies, such as VW, Audi, Bosch, Continental, and Daimler AG.

HIPAA

HIPAA is the health insurance portability and accountability act that was declared by the U.S congress in 1966. The key element of the establishment of HIPAA was to integrate electronic methods for healthcare for everyday transactions.

Additionally, the standards were meant to follow the health insurance plans for both employees as well as national identifiers. The widespread HIPAA encouraged an accentuated & effective healthcare system.

The transaction set is based on the standard x12 and key message types, which are described below in detail.

How Do HIPAA EDI Transactions Take Place?

HIPAA EDI, as aforementioned, is an exchange of electronic documents through the methods of EDI communications between medical practices and healthcare vendors. For instance, sending a healthcare claim to a health plan to request payment for medical services.

In order to provide substantial and secure EDI solutions, the service provider must follow the regulatory HIPAA standards for compliance.

HIPAA Compliance means adhering to the administrative, technical, and physical safeguards that are dictated by HIPAA to protect the health information of individuals.

The updated HIPAA compliance contains three terms – Protected health information (PHI), Covered Entity (CE), and Business Associate (BA).

• PHI refers to safekeeping the patient’s data, such as email address, social security numbers, insurance certificates & more.
• CE mentions the safekeeping of the healthcare provider data, such as doctors, clinics, pharmacies, etc.
• BA is mostly a third-party service provider that handles and secures the data of the covered entity.

Purpose of HIPAA Regulations

The main aspect of HIPAA is to protect the data integrity of Protected Health Information (PHI). The key concerns for protecting the PHI are –

• Privacy Rule – for creating privacy standards for PHI.
• Security Rule – standardizing the handling process of an electronic PHI.
• Breach Notification Rule – passes an alert to the affected parties when their health information is breached.

Violation of HIPAA can result in serious fines as per the violation level as described in the table.

No wonder, the healthcare industry has come forth, when it comes to integrating technological advancements to provide quick and valuable solutions.

Unlike other industries, the healthcare industry is completely inclined towards offering services. EDI standards are an attempt to take the benefit of technology-integrated standardization.

It is also meant to deter the communication gap resulting in the right solution.

The new EDI HIPAA compliance standards are focused on the communication aspect. As aforementioned, the critical administrative information related to the patient, such as claim format, patient medical records and much more must be exchanged, encrypting them to avoid anomalies.

How HIPAA EDI Document Standards Function?

Documents in healthcare-associated with EDI integration get converted in the non-readable format/language, which a computer easily understands. A standardized code is assigned to each documentation added to EDI.

Every transaction undergone in EDI is given a name, number, and usage information. For instance, in a transaction code – X12 834 – the ANSI x12 is the transaction standard while 834 benefit enrollment and maintenance is the transaction set.

In order to deeply understand the transaction set and standards, let’s dig deeper into HIPAA EDI more.

EDI Benefit Enrollment and Maintenance Set (834)

This transaction set is used for enrolling members through unions, government agencies, associations, or insurance agencies. The payer is usually a health care service provider who pays the benefit, claims, or claims.

EDI Healthcare Claim Payment/Advice Transaction Set (835)

One can easily and directly request for making payments or EOB remittance advice to a health care provider. This transaction set also allows the user to send both via a health insurer or a financial institution.

EDI Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

A transaction set to request the financial institution to release the payment for the payee or insured products.

EDI Health Care Claim Transaction Set (837)

This transaction set is meant to claim billing information (excluding retail pharmacy). One can easily convey claims and billing payment information among payers that hold different payment claim responsibilities.

The standard ensures coordination between payers, consistent monitoring of bills, payment, or render health care services within a specific segment.

EDI Retail Pharmacy Claim Transaction (NCPDP Telecommunications Standard version 5.1)

This transaction set is specially developed for the retail pharmacy claims to submit their claims regarding dispensing medications. The transaction set follows the same structure as that of an 837 for payment or claim process.

EDI HealthcareEligibility/Benefit Inquiry (270)

Here the insurance provider can request information related to benefits and eligibility of adding a dependent to it.

EDI Healthcare Claim Status Request (276)

In this transaction set, the insurance provider responds to the respective 270 requests raised.

EDI Healthcare Claim Status Notification (277)

In this transaction set, the request can be raised regarding additional information about healthcare. However, the scenario looks quite similar to the 835 but does not match the service.

The request may include a detailed level of summary, unlike the 835 account payment posting.

EDI Healthcare Service Review Information (278)

The transaction set 278 is raised to underline the healthcare service reviews. Here transfer of detailed information about the patient – its name, treatment, diagnosis of illness, and demographics are requested to observe certifications, notifications, and reviews to report the outcome.

EDI Functional Acknowledgement Transaction Set (997)

This set is not mentioned as a dedicated transaction set By HIPAA in its rule book, yet it is the most vital for X12 standard processing.

The method of data interchange is maintained and controlled through a set of acknowledgments.

The information of documents is encoded to form a transaction set, further which is combined in a functional group for data interchange.

To Conclude –

Since it is a shared responsibility for healthcare payers, identifiers, and financial institutions to link and communicate together to meet the request aligned, HIPAA EDI standards are furnished to make this process seamless while responding to every request.

An efficient and reliable EDI solutions provider can support you with the compliance and standard integration within your existing system without the need for a new resource, which will further inculcate smooth communication and requisite capabilities.

Author’s Bio: Scarlett works with the editorial team of A3logics, a leading company offering professional IT services.

Exploring the latest technologies, reading about them, and writing her views have always been her passion.

She seeks new opportunities to express her opinions, explore technological advancements, and document the details. You can always find her enjoying books or articles about varied topics or jotting down her ideas in a notebook.

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