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Unlocking the Power of EDI in Healthcare: A Complete Overview

January 5th, 2024

Healthcare organizations deal with huge amounts of data every day, from patient records and claims to lab results and prescriptions. However, not all data is created equal. Different systems and formats can make data exchange difficult, costly, and error-prone.

Approximately 50% of US hospitals believe the growing volume of unstructured data will become the biggest obstacle to improving healthcare interoperability, undermining connected care initiatives. Fortunately, there is a reliable solution that can help hospitals overcome these challenges: healthcare EDI transactions. 

EDI transactions can simplify and automate many healthcare processes, such as billing, enrollment, eligibility verification, and referrals. By using EDI transactions, healthcare organizations can improve their data quality, accuracy, and security, while saving time and money. 

In this blog, we provide a comprehensive overview of EDI transactions in healthcare and explain how they can optimize healthcare operations and enhance patient care.

What Does EDI Stand for in Healthcare? 

EDI stands for Electronic Data Interchange, a technology that allows healthcare organizations to exchange data in a standardized and structured way.

At the core of healthcare EDIs are the ANSI X12 (American National Standards Institute X12) and HIPAA (Health Insurance Portability and Accountability Act) standards, standardizing data exchange through established formats and protecting patient privacy. These standards help establish a common language for exchanging sensitive healthcare data, enabling seamless interoperability between different systems and organizations. 


Benefits of EDI in healthcare

The transformational benefits of EDI in healthcare

The Importance of EDI in Healthcare 

Ensuring Standardization and Efficiency 

88% of hospitals engage in health data exchange, according to a study by ONC Interoperability. However, the variability of information systems and the absence of data standards present significant challenges to hospitals that want to leverage public health data effectively. 

EDI enables secure and standardized data exchange between healthcare stakeholders. It establishes a common language and format for transmitting information, ensuring system consistency and compatibility.  

One prime example of this is submitting claims using EDI transactions like EDI 837. Instead of laboriously preparing and submitting paper-based claims, healthcare providers can electronically transmit comprehensive claim information, including patient demographics, diagnosis codes, procedures performed, and associated charges.  

This automated process eliminates the need for manual paperwork, drastically reducing the chance of errors or missing information. The benefit of using EDI extends beyond efficiency. Providers experience faster claim processing and adjudication as payers can receive and process electronic claims more efficiently, resulting in quicker reimbursement and improved financial management.  

Healthcare edi 837

Data typically shared via EDI 837 Claims in healthcare

Moreover, EDI ensures data accuracy and completeness in claim documentation. The standardized format and validation checks within EDI transactions help identify errors or missing information upfront, greatly reducing the likelihood of claim denials or rejections. Providers can also include all necessary supporting documentation electronically, ensuring a thorough and accurate representation of the services provided. 

Lastly, EDI helps providers and payers improve communication and collaboration. This streamlined communication enables all parties to efficiently communicate regarding claim statuses, requests for additional information, or any discrepancies.  

Ensuring Compliance 

Leveraging EDI in healthcare is a practical necessity and strategic imperative for healthcare providers. In 2023 alone, healthcare providers were issued penalties of almost $2 million for non-compliance with HIPAA. 

According to CMS’ Interoperability and Patient Access rule, fax numbers and emails are insufficient for compliance. The HIPAA EDI Rule also mandates healthcare entities to adhere to the ASC X12 protocol for all healthcare-related EDI transactions. Therefore, leveraging EDI ensures compliance with regulatory requirements such as HIPAA and Medicare, safeguarding data security and privacy across the care continuum.  

Providers can leverage EDI to meet quality reporting requirements for programs like PQRS and MIPS, reducing errors and ensuring compliance. With support for electronic health records, EDI allows providers to meet EHR meaningful use criteria and demonstrate compliance with incentive programs. 

Healthcare organizations mitigate the risk of data breaches, unauthorized access, and non-compliance penalties by following these compliance and security protocols. It demonstrates a commitment to protecting patient information, thus maintaining trust with patients, payers, and other stakeholders. 

Minimizing Claim Denials 

The financial impact of claim denials is significant, with unresolved denials causing an average annual loss of $5 million for hospitals, amounting to up to 5 percent of their net patient revenue. Denial rates have been on the rise, surpassing 20 percent in the past five years, and average claim denial rates are now at 10 percent or higher. 

On the practice side, respondents reported a 17% increase in denials in 2021 alone. Another challenge is the complexity of a single claim request, which may involve up to 350 data elements. Therefore, maintaining accuracy while processing these requests manually is extremely difficult. 

impact of manual claims processing

How manual claims processing is hurting provider-payer relationships in the United States.

EDI healthcare transactions play a critical role in minimizing claim denials and optimizing revenue cycle management for new healthcare delivery models. EDI enables real-time validation and standardized claims data transmission, ensuring accuracy and completeness before submission. This capability helps providers identify and correct errors quickly, reducing the likelihood of denials due to incomplete or inaccurate information.

Likewise, the standardized format of EDI transactions ensures compliance with payer requirements, further minimizing denials and improving claims acceptance rates. Additionally, automated EDI claims submission expedites turnaround times, streamlining claims processing and enhancing communication with payers. As a result, these transactions mitigate potential errors or delays and reduce the chance of delayed or denied claims.

Lastly, EDI transactions in healthcare, such as the 835 Claim Payment Advice transaction, also known as remittance advice, provide detailed explanations for claim denials. Equipped with this information, providers can proactively address the reasons for denials and take corrective actions to prevent similar issues in the future. 

Minimizing Costs 

Administrative tasks account for 25% of US healthcare spending, creating an annual expenditure of $250 billion. EDI plays a crucial role in minimizing costs for healthcare providers by automating processes, reducing paperwork, improving efficiency, lowering transaction costs, and enhancing accuracy. 

EDI automates various administrative tasks like data entry and claims management, helping providers save time and resources. Eliminating paper-based processes cuts costs and reduces the likelihood of errors. With greater data accuracy, EDI helps reduce claims rejections and associated administrative expenses.  

Moreover, standardizing and automating transactions contributes to lower transaction costs. As per the Council for Affordable Quality Healthcare (CAQH) Index, EDI-enabled medical transactions cost 7.34 times less than manual transactions in 2022, costing $0.67 per transaction instead of $4.92 per manual transaction. 

Ensuring Interoperability for Better Patient Outcomes 

Patients in a diverse healthcare system often receive care from multiple providers and organizations. Without robust information exchange, important medical history, test results, and treatment plans may not be readily available to all involved healthcare professionals. Lack of comprehensive information can lead to delayed diagnoses, inappropriate treatments, and compromised patient safety. 

“Almost 70% of digital health companies reported encountering incomplete or insufficient patient data when obtaining it from third-party vendors” – Statista 

EDI ensures the secure exchange of patient data, health records, lab results, and other clinical information among care team members. Likewise, EDI promotes interoperability and standardization, ensuring the smooth flow of critical patient information across different healthcare settings and among various care team members. 

Streamlined information sharing enhances care coordination and enables evidence-based diagnosis. As a result, healthcare providers overcome traditional barriers to information sharing, such as missing data, incompatible systems, disparate formats, and data silos. With access to complete data and comprehensive patient insights, they can deliver more personalized and effective care. 

For instance, healthcare EDIs allow users to exchange clinical documents, such as Continuity of Care Documents (CCDs). Likewise, EDI 275 enables providers to exchange additional patient information, such as discharge summaries, certificates of medical necessity, and operative reports.  

This exchange allows other providers to access patient medical histories and relevant clinical information. They no longer have to rely on manual processes, such as faxing or mailing paper documents, which can be time-consuming and error-prone. Ultimately, EDI streamlines processes like claim adjudication, preadmission screening, authorization requests, or other healthcare services review.   

By helping providers to exchange patient information seamlessly, EDI promotes care coordination, enabling a comprehensive view of patient data and facilitating informed decision-making. Healthcare providers can deliver more personalized and effective care with improved interoperability, improving patient outcomes.

The Impact of Healthcare EDI on New Models of Healthcare Delivery 

The US healthcare system is undergoing a profound transformation, driven by the need for more efficient, patient-centered, and value-based care. Healthcare EDI is sustaining new healthcare delivery models by enabling collaboration and information exchange and enhancing care coordination. 

Accountable Care Organization (ACO) 

The Accountable Care Organization (ACO) model focuses on enhancing care coordination, improving patient outcomes, and reducing healthcare costs through a network of collaborating providers.  

For instance, when a patient requires a specialist referral, the primary care physician can use EDI transaction sets like the Continuity of Care Document (CCD) or Healthcare Services Review ( EDI 278) to electronically transmit relevant patient information to the specialist. These transaction sets ensure the transfer of comprehensive information, enabling personalized care and improved outcomes. 

EDI also plays a crucial role in care coordination within the ACO model. Transaction sets such as the Health Care Claim (837) and Eligibility Inquiry (270) facilitate the exchange of claims information and eligibility verification. Providers can electronically submit and process claims, reducing administrative burdens and enhancing efficiency throughout the ACO. 

Additionally, EDI supports population health management within the ACO. Transaction sets like the Health Care Claim (837) and Health Risk Assessment (HRA) enable the secure exchange of population data, including demographic information and disease registries. 

This data-driven approach empowers providers to identify at-risk populations, implement preventive measures, and proactively manage chronic conditions. By leveraging EDI transaction sets in population health management, providers can ensure better outcomes and reduced costs. 

Patient-Centered Medical Home (PCMH) 

The Patient-Centered Medical Home (PCMH) model emphasizes comprehensive, coordinated and patient-centered care through a team-based approach. It focuses on enhancing the patient experience, improving care quality and outcomes, and reducing healthcare costs. 

“PCMHs produce most effective cost savings in highest risk patients.” –Pennsylvania Chronic Care Initiative 

For example, using EDI transaction sets like the Continuity of Care Document (CCD), Electronic Lab Result Reporting (ELR), and Referral Authorization (278I), healthcare providers within the PCMH can efficiently share critical information. Consider a scenario where a patient with chronic conditions visits their primary care provider. 

The provider needs to consult with a specialist and refer the patient for further evaluation. Using EDI, the primary care provider electronically sends the referral information, including medical history, medications, and the reason for the referral, to the specialist. This ensures the specialist has the necessary context for specialized care. 

The specialist can then use EDI to send the consultation report and recommendations back to the primary care provider, seamlessly integrating the information into the patient’s electronic health record. This enables the primary care provider to review and coordinate the next steps in the patient’s care plan. 

Specialist Hospitals and Population-Specific Care Units 

Specialist Hospitals and Population-Specific Care Units are specialized healthcare facilities that provide tailored services to improve patient outcomes and experiences for specific medical conditions or populations. 

However, implementing this model poses challenges in coordinating with primary care providers and allocating resources effectively. EDI addresses these challenges by enabling the seamless exchange of patient information, diagnostic reports, and treatment plans.  

Furthermore, EDI enables ongoing communication and collaboration between specialized hospitals and referring providers. Transaction sets such as Health Care Claim Status Request (276/277) facilitate the electronic sharing of updates on patient progress, test results, and treatment adjustments. EDI-enabled coordination and communication ultimately lead to improved patient outcomes in specialist hospitals and population-sp 

EDI Healthcare Provider Benefits


EDI X12 Healthcare Use Cases 

EDI streamlines several key processes in US healthcare. Let’s explore the healthcare EDI transactions list to see how they benefit healthcare payers and providers alike: 

Healthcare Use Case  Transaction Set  Role for Payers  Role for Providers 
Processing Claims  EDI 837  Receive and process claims for payment  Submit claims for reimbursement 
Verifying Patient Eligibility and Benefits  EDI 270/271  Determine patient’s coverage and benefits  Obtain information on patient’s benefits 
Inquiring and Verifying Prior Authorization  EDI 278  Request pre-authorization for services  Respond to pre-authorization requests 
Enabling Remittance Advice  EDI 835  Provide payment details and explanations  Track payments and reconcile accounts 
Exchanging Referral Information  EDI 278  Request and verify referral information  Respond to referral requests 
Transmitting Provider Information  EDI 274  Update provider information  Communicate changes to provider details 
Coordinating Benefits  EDI 837 COB  Coordinate benefits with other payers  Coordinate benefits with other providers 
Exchanging Patient Information  EDI 275  Share patient information with stakeholders  Receive and integrate patient information 
Managing Payments and Remittance  EDI 820  Initiate payment orders and remittance  Receive and reconcile payment information 
Managing Benefit Enrollment and Maintenance  EDI 834  Manage benefit enrollment and changes  Transmit enrollment and changes 
Acknowledgment and Confirmation  EDI 997, EDI 999, EDI TA1  Confirm receipt and acceptance of EDI transactions  Acknowledge receipt and validation of EDI transactions 

Learn More about EDI Payer Use Cases (Internal Link) 

EDI in Healthcare: The Perfect Medium for Reliable and Secure Data Exchange 

EDI healthcare transactions are a secure and efficient way of exchanging data between healthcare institutions, insurers, and patients using established standards and formats. These solutions help healthcare organizations reduce delays and improve the quality and coordination of care. With a reliable EDI solution, healthcare organizations can handle streamline claims, eligibility, status, and payment management while complying with HIPAA standards. 

Astera EDIConnect is a powerful and flexible EDI software solution that enables users to easily generate, parse, validate, and translate any healthcare EDI transaction—all with no code.  

The tool enables healthcare organizations to easily integrate EDI data with any database, application, or system using a drag-and-drop interface and pre-built connectors. Customize EDI workflows, apply business rules, and seamlessly onboard business partners in real-time. 

Don’t miss this opportunity to streamline healthcare data exchange and improve operational efficiency. Discover how Children’s Community Health Plan (CCHP) maximized claims reimbursements by leveraging the power of automated EDI workflows.  


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