EDI Rules

HIPAA electronic data interchange, also known as HIPAA EDI, is the electronic transfer of information in a standard format. It allows for the exchange of information in a fast and cost-effective way.

According to the Department of Health and Human Services, HHS, this lack of standardization:

  • makes it difficult and expensive to develop and maintain software; and
  • reduces the ability of health care providers and health plans to achieve efficiencies and savings.

Transferring information in an electronic fashion can eliminate the inefficiencies of handling paper documents, as well as providing an opportunity for both parties to reduce administrative burden, lower operating costs, and improve overall data quality. 

In order to ensure the efficiency of this process, HHS has adopted record formats for certain transactions. These record formats are called "standards". The standards specify the format, data content and code sets to be used for each transaction. Covered entities, which are required to use these standards, are prohibited from altering these standards when exchanging data. 

By using these transaction standards, we now have the ability to exchange information in a fast and cost-effective way. 

The HIPAA EDI Rule defines 3 groups, referred to as Covered Entities that must comply with the HIPAA EDI Rule. The Covered Entities are Health Plans, Health Care Clearinghouses, and Health Care Providers.

We are a Health Plan when conducting business activities for certain of its products, called "covered products." The majority of our products are exempt from the HIPAA EDI Rules. For example, Long Term Disability (fully insured and self insured), Short Term Disability (fully insured and self insured), Life and Accident coverages are all excluded. Products that are "covered products" include long term care, expense base cancer, hospital confinement, dental, vision or intensive care policies, certain medical coverages and other health plans pursuant to the Health Insurance Portability and Accountability Act ("HIPAA")

We have the ability to conduct the HIPAA regulated transactions with respect to its covered product when required to by the regulation. At this time, we cannot support HIPAA EDI transaction standards for the remainder of our portfolio.

Please click on any of the links below for more information on:

  • The HIPAA EDI transaction standards that impact our covered products. Read more
  • Our response to some frequently asked questions about the HIPAA EDI Rules. Read more

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.

EDI Transaction Standards

Enrollment

Numerical identifier: 834
Transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.

Premium payment

Numerical identifier: 820
Transmission of any of the following to a health plan from the entity that is arranging for the provision of health care coverage payments or is providing health care coverage payment for an individual:

  • Payment
  • Information about the transfer of funds
  • Detailed remittance information about individuals for whom premiums are being paid
  • Payment processing information to transmit health care premium payments including any of the following:
  1. Payroll deductions
  2. Their group premium payments
  3. Associated group premium payment information

Eligibility inquiry

Numerical identifier: 270
An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:

  • Eligibility to receive health care under the health plan
  • Coverage of health care under the plan
  • Benefits associated with the health plan

Eligibility response

Numerical Identifier: 271
A response from a health plan to health care providers (or another health plan). Eligibility Inquiry (270 defined above).

Claim/encounter transaction

Numerical Identifier: 837
A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. 

If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.

Coordination of benefits transaction

Numerical Identifier: 837 COB
Transmission from any entity to a health plan:

  • Health care claims, or
  • Health care payment information

For the purpose of determining the relative payment responsibilities of the health plan.

Remittance advise (explanation of benefits)

Numerical Identifier: 835
Transmission of either of the following for health care:

  • Transmission of any of the following from a health plan to a health care provider's financial institution:
    1. Payment
    2. Information about the transfer of funds
    3. Payment processing information
  • Transmission of either of the following from a health plan to a health care provider:
    1. Explanation of benefits
    2. Remittance advice

Claim status inquiry

Numerical identifier: 276
An inquiry to determine the status of a health care claim.