X12 EDI FAQ

X12 EDI Frequently Asked Questions

Welcome to the comprehensive FAQ page for X12 EDI at PilotFish, where you can find all the information you need about implementing and optimizing Electronic Data Interchange (EDI) in insurance, healthcare and other industries. Whether you’re new to EDI or looking to refine your existing processes, PilotFish’s expertise and advanced middleware solutions are designed to enhance efficiency and compliance with ease. Dive into our FAQs to learn more about how PilotFish can streamline your EDI transactions.

What is X12 EDI?

X12 EDI is a data format based on ASC X12 standards developed by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). It is used to electronically exchange business documents in specified formats between two or more trading partners. X12 EDI releases are known by a version number. Learn more about PilotFish’s Interface Engine with exclusive X12 EDI tools to process all your transactions.

What is the X12 format?

X12 is a standard for Electronic Data Interchange (EDI) developed and maintained by the American National Standards Institute (ANSI) Accredited Standards Committee (ASC). The X12 standard governs the exchange of business documents (e.g., purchase orders, invoices, healthcare claims, etc.) in standard electronic formats between trading partners – for example, EDI 837 Health Care Claim Transaction Set. PilotFish provides broad support for all X12 standards and HIPAA transactions.

What is EDI?

Electronic data interchange (EDI) is the structured exchange of business documents between organizations by electronic means based on widely accepted and agreed to standards. EDI standards govern electronic data exchange in finance, government, healthcare, insurance, retail, transportation and more.

What does EDI stand for?

EDI is an abbreviation and shorthand for Electronic Data Interchange, a structured way to transmit data between computer systems using established message formats and standards. The businesses or organizations exchanging data are called trading partners in EDI terminology.

What is an EDI transaction?

An EDI transaction set or EDI transaction is a group of one or more data segments representing a business document exchanged between trading partners to carry out financial or administrative activities – e.g., EDI 820 Payment/Remittance, EDI 999 Acknowledgment, EDI 834 Benefit Enrollment/Maintenance. The standard prescribes the formats, character sets and data elements used. View the format & description of the most common X12 EDI transactions.

What is EDI capable?

EDI capable is the ability to send and receive electronic business documents in a specific format based on established standards. It also refers to having in place an EDI solution that can streamline business workflows and onboard partners quickly. EDI capable can further encompass strategy and solutions that deliver efficiencies and high productivity. Learn more about PilotFish’s EDI Capable Integration Engine with built-in X12 EDI tools.

What is EDI parsing?

EDI parsing is the process of matching the incoming data with a defined schema to identify, flag and/or fix data transformation issues. EDI parsing errors include data type mismatches, invalid records, incorrect values, incorrect segment and element usages, etc. While X12 EDI formats are based on the published standards – in the real world, deviations and differences between X12 EDI transactions are the norm. Learn more about PilotFish’s built-in EDI parser.

What is EDI mapping?

EDI mapping is the process through which EDI data is translated and transformed into a format more easily used or required by a trading partner or both. Data mapping is the capability to map source data fields to related target data fields in converting EDI to other formats such as XML, Excel, databases, JSON or other EDI formats. Learn more about EDI mapping with PilotFish.

Which is better EDI or API?

EDI (Electronic Data Interchange) is used for the transfer of structured data, by agreed message standards, from one computer system to another without human intervention. EDI is one of the safest ways to transfer data. Companies can exchange large amounts of EDI data simultaneously as well as transfer huge volumes via a single transfer. An API (Application Programming Interface) is a connection between computers or between computer programs via calls, working on a request-response basis.

Is API better than EDI?

Application Programming Interfaces (APIs) work on a request-response basis. They are not intended for transactional interfaces or standards-based integration. While very beneficial in many integration scenarios, creating APIs and integrating with them also requires programming expertise. For most backend internal system integrations, APIs are more costly to develop and maintain. Increasingly, trading partners are using a mix of APIs and EDI.

What is healthcare EDI?

Most commonly, healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) rules requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status inquiries, remittance advice and benefit enrollment.

What is HIPAA EDI?

In the electronic exchange of financial and administrative healthcare transactions, the Health Insurance Portability and Accountability Act (HIPAA) requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/ authorization and premium payment to health insurance plan.

What are healthcare EDI transactions?

In EDI, a single business document is called a “transaction set” or “message.” HIPAA requires all health plans, healthcare clearinghouses and healthcare providers to use HIPAA X12 EDI transaction sets for structured message exchange. Electronic transactions covered include healthcare claims, claims status and remittance advice, eligibility verifications and responses, referrals and authorizations, and coordination of benefits.

HL7, EDI & FHIR Data Integration for Reporting & Analytics with PilotFish

HL7, EDI & FHIR Data Integration for Reporting & Analytics

How does EDI work in healthcare?

Healthcare EDI refers to the HIPAA (Health Insurance Portability and Accountability Act) requirement that any health plan, healthcare clearinghouse and healthcare provider transmit claims and other patient-identifiable health information in specific X12 EDI healthcare transaction sets. HIPAA EDI transactions include claims, encounters, eligibility, claim status, remittance advice and benefit enrollment.

What is an EDI claim?

HIPAA X12 EDI transaction sets are structured messages standardized and required for claims submission, enrollment/disenrollment, eligibility, payment to provider, claims status, certification/authorization and premium payment to health insurance plans by all health plans, healthcare clearinghouses and healthcare providers.

How does EDI work in medical billing?

EDI allows entities within the healthcare ecosystem to exchange medical, billing and other information quickly and cost effectively. Medical billing involves timely exchange of specific HIPAA EDI documents (claims, remittance advice, eligibility inquiry, claim status inquiry), accurate medical coding, and secure information exchange to and from provider and payer entities as well as third-party vendors and clearinghouses.

What are some benefits of using EDI for healthcare data exchange?

EDI can help reduce costs, improve accuracy and efficiency, enhance patient privacy and security, and improve overall healthcare quality and outcomes.

What are some emerging trends in EDI healthcare?

Cloud-based EDI solutions, blockchain technology, and AI driven analytics are some emerging trends in EDI healthcare parsing and validation.

What is EDI healthcare data conversion, and how does it work?

EDI healthcare data conversion is the process of converting healthcare data into EDI format to enable secure transmission and integration into other systems. It involves mapping data elements from the source format to EDI standards, such as X12.

What are the benefits of using EDI in healthcare data integration?

EDI enables secure and real-time exchange of healthcare data between providers, payers, and patients. It helps reduce errors, streamline workflows, and improve data accuracy and patient care.

What is EDI 834 data conversion, and why is it important for technical users interested in PilotFish’s integration tools?

Electronic Data Interchange (EDI) 834 data conversion is the process of translating data between different formats, often involving transforming data from CSV, XLS/Excel, or TXT to the EDI 834 format used for Benefit Enrollment and Maintenance. For technical users considering PilotFish’s integration tools, this process is vital as it enables seamless data communication between systems, facilitating efficient data integration and management. Watch our EDI 834 Transformation Video.

What is the role of EDI in healthcare supply chain management?

EDI enables healthcare organizations to automate supply chain management processes, such as inventory tracking, order processing, and invoicing. It helps reduce manual errors, improve efficiency, and increase supply chain visibility.

What are the key considerations for selecting an EDI software provider for healthcare data conversion and integration?

Key considerations include expertise in healthcare EDI, knowledge of industry regulations, reliability and scalability of the platform and support and training services.

How can healthcare organizations integrate EDI with their existing EHR and practice management systems?

Healthcare organizations can integrate EDI by using middleware solutions that enable seamless data exchange between different systems, or by using APIs that enable real-time data transfer between systems. See EHR Integration Solutions.

What are the key benefits of using EDI for healthcare data conversion and integration?

Key benefits include improved data accuracy and timeliness, reduced costs and errors, increased efficiency and productivity, enhanced patient care and outcomes, and compliance with industry regulations and standards.

What are some common EDI healthcare transactions?

Claim submissions (EDI 837), remittance advice (EDI 835), eligibility verification (EDI 270/271), and prior authorization (EDI 278) are some common EDI healthcare transactions.

What are the HIPAA X12 transaction sets?

The key X12 EDI transaction sets specified by HIPAA include:

  • EDI 270 Healthcare Eligibility/Benefit Inquiry
  • EDI 271 Healthcare Eligibility/Benefit Response
  • EDI 275 Patient Information
  • EDI 276 Healthcare Claim Status Request
  • EDI 277 Healthcare Claim Status Notification
  • EDI 277 Healthcare Claim Acknowledgment
  • EDI 278 Healthcare Service Review Information
  • EDI 820 Payroll Deducted and other group Premium Payment for Insurance Products
  • EDI 824 Application Advice
  • EDI 834 Benefit Enrollment and Maintenance
  • EDI 835 Healthcare Claim Payment/Advice
  • EDI 837 Healthcare Claim and Maintenance
  • EDI 997 Functional Acknowledgment for Healthcare Insurance
  • EDI 999 Functional Acknowledgement
  • EDI TA1 Interchange Acknowledgment

What X12 EDI supply chain transactions are used in healthcare?

Common Types of X12 EDI Supply Chain Transactions include:

Does PilotFish support all X12 EDI 5010 healthcare transaction sets including 270/271, 275, 276/277, 277CA, 277P, 278, 820, 824, 834, 835, 837 I/P/D, 999?

Yes, PilotFish fully supports all the X12 EDI 5010 transaction sets.

Where does the EDI 835 and EDI 837 data typically come from?

The EDI 835 and 837 data, essential in healthcare EDI (Electronic Data Interchange), usually originates from healthcare clearinghouses or practice management systems. The EDI 835 transaction covers healthcare claim payments, while the EDI 837 transaction involves claim submission. The data extraction process can vary based on the source system. For more details, see our EDI 837 demo video or read this HIE & Claims Clearinghouse case study.

What is EDI 270 Eligibility, Coverage of Benefit Inquiry?

The EDI 270 transaction set and format is used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or dependent under the subscriber’s policy. The transaction set may be used by all lines of insurance such as Health, Life, and Property and Casualty. For more detailed information see EDI 270 format and example.

What is EDI 271 Eligibility, Coverage of Benefit Information?

The EDI 270 transaction set and format is used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as – insurers, sponsors, payors) to information receivers (such as – physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, co-insurance, co-pays, deductibles, exclusions and limitations. For more detailed information, see EDI 271 format and example or read this EDI 271 integration case study.

What is EDI 275 Patient Information?

The EDI 275 transaction set is used to communicate individual patient information requests and patient information between separate health care entities in a variety of settings to be consistent with confidentiality and use requirements. Patient information consists of demographic, clinical, and other supporting data. The EDI 275 can be sent either solicited or unsolicited. The EDI 275 Patient Information is an EDI transaction designed to carry attachments. For more detailed information, see EDI 275 format and example.

What is EDI 276 Healthcare Claim Status Request?

The EDI 276 transaction set is used by a provider, recipient of healthcare products or services, or their authorized agent to request the status of a healthcare claim or encounter from a healthcare payer. Note: EDI 276 does not replace the EDI 837 Healthcare Claim transaction set, but is intended for use after the receipt of a claim or encounter information. Such a request may occur at the summary or service line detail level. For more detailed information, see EDI 276 format and example.

What is EDI 277 Healthcare Claim Status Notification?

The EDI 277 is used by a healthcare payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a healthcare claim or encounter or to request additional information from the provider regarding a healthcare claim or encounter, healthcare services review, or transactions related to the provisions of healthcare. The notification may be solicited or unsolicited. EDI 277 does not replace the Healthcare Claim Payment/Advice Transaction Set (EDI 835). It is not used for account payment posting. The notification may be at a summary or service line detail level. For more detailed information, see EDI 277 format and example.

What is EDI 277 Healthcare Claim Status Response?

The EDI 277 is Acknowledgement/Returned as Unprocessable Claim-The claim/encounter has been rejected and has not been entered into the adjudication system. The EDI 277 transaction set has been specified by HIPAA for the submission of claim status information to respond to a previously received EDI 276 Claim Status Inquiry, to request that a payer provide additional information about a submitted claim (no 276 involved), or for a payer to provide claim status information to a provider via the EDI 277, without having received a 276.

What is EDI 277CA Healthcare Claim Acknowledgment?

The EDI 277CA Healthcare Claim Acknowledgment provides a claim level acknowledgment of all claims received in the payer’s pre-processing system before submitting claims into an adjudication system. It is created in receipt of an incoming EDI 837 5010 claim submission transaction. The 277CA offers a common report interface to payers and providers. Most clearinghouses and payers now use the 277CA as their standardized reporting mechanism for 5010. The 277CA reports on whether pre-adjudication validation found the claims acceptable for adjudication. There are no Category Codes signifying ‘accepted with warning’. The 277CA cannot report syntax issues. The EDI 277CA transaction is not required by HIPAA. For more information, refer to the TR3 Implementation Guide (Technical Report Type 3).

What is EDI 278 Healthcare Services Review Request?

The EDI 278 transaction set can be used to transmit healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

What is EDI 278 Healthcare Services Review Response to a Request?

The EDI 278 transaction set can be used to responses to requests for healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a healthcare services review. A single 278 is commonly used for one patient and one patient event. For more detailed information, see EDI 278 format and example.

What is EDI 820 Payment Order/Remittance Advice?

The EDI 820 transaction set can be used to make a payment, send remittance advice, or make a payment and send remittance advice. This transaction set can be an order to a financial institution to make a payment to a payee. It can also be a remittance advice identifying the detail needed to perform cash application to the payee’s accounts receivable system. The remittance advice can go directly from payer to payee, through a financial institution, or through a third-party agent. For more detailed information, see EDI 820 format and example or read this EDI 820 integration case study.

What is EDI 824 Application Advice?

The EDI 824 acknowledgment is used as a means of communicating errors in a previous transaction. The EDI 824 report allows the trading partner who sent the original transaction to identify, correct and resubmit that transaction. In healthcare applications, the optional EDI 824 transaction meets HIPAA 5010 requirements for non-claims (EDI 276, 270 and 278) transactions. In practice, EDI 824 is used or even required as an acknowledgment to EDI 837 Claims as well. The 824 acknowledgment also is used report the success of failure of an EDI 275 attachment transaction. The 824 can embed an HL7 report on the acceptance of the HL7 or identifying specific HL7 syntax errors. For more detailed information, see EDI 824 format and example.

What is EDI 834 Benefit Enrollment and Maintenance?

The EDI 834 transaction set can be used to establish communication between the sponsor of the insurance product and the payer. The sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency. The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, etc.), or an entity that may be contracted by one of these former groups. For more detailed information, see EDI 834 format and example or read the EDI 834 integration case study.

What is EDI 835 Healthcare Claim Payment & Remittance Advice?

The EDI 835 Healthcare Claim Payment and Remittance Advice transaction set is used by insurance plans to make payments to healthcare providers and/or provide Explanations of Benefits (EOBs) remittance advice. When an EDI 837 Healthcare Claim is submitted by a healthcare service provider, the healthcare insurance plan uses the EDI 835 to detail the payment to that claim. What charges were paid, denied, or adjusted; the presence of a deductible, co-insurance, co-pay, etc.; bundling or splitting of claims or line items; how payment was made (e.g. clearinghouse). Healthcare providers use the 835 to track what payments were received for the services they provided and billed. For more detailed information, see EDI 835 format and example or read this EDI 835/837 revenue recovery case study.

What is EDI 837 Healthcare Claim: Professional?

The EDI 837 or 837P transaction set is used for electronic claims from providers and health plans for services performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services. This transaction set is sent by the providers to payers, which include insurance companies, health maintenance organizations (HMOs), preferred provider organizations (PPOs), or government agencies such as Medicare, Medicaid, etc. These transactions may be sent either directly or indirectly via clearinghouses. For more detailed information, see EDI 837 format and example or read this EDI 837 integration case study.

What is EDI 837 Healthcare Claim: Dental?

The EDI 837 or EDI 837D transaction set is used for electronic claims from providers and health plans that use EDI for dental procedures. EDI 837D can be used to submit dental claim billing information, encounter information, or both. Submitters can be providers of approved categories of dental care to payers, either directly or via intermediary billers and claims clearinghouses. For more detailed information, see EDI 837 format and example.

What is EDI 837 Healthcare Claim: Institutional?

The EDI 837 or EDI 837I transaction set is used to transmit institutional claims submitted by hospitals and skilled nursing facilities. EDI 837I can be used to submit healthcare claim billing information, encounter information, or both. Submitters can be providers of healthcare services to payers, either directly or via intermediary billers and claims clearinghouses. For more detailed information, see EDI 837 format and example.

What is EDI 997 Functional Acknowledgment?

The EDI 997 Functional Acknowledgment describes the syntax-level acknowledgment of the receipt of an X12 functional group. It confirms to a sender that a receiver has received the EDI transactions successfully. In addition, the acknowledgment contains an acceptance or rejection notification. HIPAA EDI Version 5010 of the standards established EDI 999 as the healthcare standard acknowledgment document, designed to replace Version 4010 997 Functional Acknowledgment. You may encounter both the 997 and 999 in use. For more detailed information, see EDI 997 format and example.

What is EDI 999 Implementation Acknowledgment?

The EDI 999 transaction set is used to define the control structures for a set of acknowledgments to indicate the results of the syntactical and relational analysis of the electronically encoded documents, based upon a full or implemented subset of X12 transaction sets. EDI 999 does not encompass the semantic meaning of the information encoded in the transaction sets. For more detailed information, see EDI 999 format and example.

What is EDI TA1 Interchange Acknowledgment?

The EDI TA1 Interchange Acknowledgment is used to verify the syntactical accuracy of the envelope of the X12 interchange. The TA1 will indicate that the file was successfully received, as well as indicate what errors existed within the envelope segments of the received X12 file. The TA1 verifies the envelope only. For more detailed information, see EDI TA1 format and example.

How can healthcare providers ensure data integrity during EDI data conversion?

Healthcare providers should implement robust data validation, verification, and reconciliation procedures to ensure data integrity during EDI data conversion. They should regularly monitor their EDI systems for errors or discrepancies. See eiDashboard for Real-Time Transaction Monitoring.

What are some common challenges in EDI healthcare data conversion and integration?

Some common challenges include data mapping errors, EDI compliance issues, data validation and reconciliation, and interoperability issues between different systems. See HIPAA Validation & Compliance.

What are some best practices for implementing EDI healthcare data conversion and integration?

Best practices include selecting the right EDI software, choosing an experienced EDI software company, conducting thorough testing and validation, implementing robust security measures, and regularly monitoring and maintaining the EDI system.

How does EDI healthcare data conversion help with HIPAA compliance?

EDI healthcare data conversion can help healthcare organizations comply with HIPAA regulations by enabling secure and compliant transmission of electronic healthcare transactions with the right middleware. See SNIP Validation.

How can healthcare organizations ensure EDI compliance with different trading partners?

Healthcare organizations should have a clear understanding of their trading partners’ EDI requirements and ensure their EDI software and processes are compatible. They should also monitor and maintain compliance with EDI standards and regulations.

What is HIPAA SNIP validation?

HIPAA SNIP validation is applied to X12 EDI documents to ensure the EDI data is HIPAA-compliant. Each succeeding WEDI-SNIP Type 1-7 increases the strictness of data constraints. Support of the higher SNIP levels (SNIP Types 4-7) in an EDI solution helps to ensure robust validation and HIPAA EDI compliance checks.

How are EDI X12 files validated?

Several parts of an EDI message can have problems that corrupt or invalidate the message contents. The EDI specification includes SNIP Types 1-7 (SNIP Levels) that define checks to make sure a given EDI message is EDI compliant and passes specific criteria for being well-formed. PilotFish provides SNIP validation out-of-the-box for Types 1-3 and Types 4-7 as an add-on. An additional EDI SNIP Validation Processor provides a preliminary overall sanity check.

Does PilotFish offer a comprehensive rules engine for HIPAA-compliant EDI file validation and error reporting?

Absolutely. PilotFish expertly conducts SNIP validations, ensuring both integrity and compliance. For example, EDI 835 files that are generated from EDI 837 files. This meticulous validation process not only identifies errors but also presents the findings in a user-friendly XML format. Additionally, users have the flexibility to either generate detailed reports or opt for exceptions based on these validation outcomes.

Does PilotFish provide comprehensive SNIP Levels 1 to 3 validation?

Yes, PilotFish’s base products include a thorough validation that spans the entire spectrum of SNIP standards, ensuring a detailed and complete verification process far beyond mere surface-level checks. SNIP 1-3 is included automatically and SNIP 4-7 are optional add-ons.

What are the costs associated with external code set maintenance?

PilotFish’s external code set maintenance service, which is vital for the current maintenance of EDI transaction codes, is available for yearly updates. Fill out our Contact Us form to connect with a sales representative for pricing.

How often are the HIPAA code sets updated with the maintenance service?

PilotFish has an automated process so that code sets are updated regularly in accordance with official releases and regulatory updates. This ensures your organization always operates with the most current information. To learn more, visit our External Code Set Maintenance page.

What is the pricing structure for PilotFish’s External HIPAA Code Set Maintenance Service?

PilotFish’s External Code Set Maintenance Program is only available to PilotFish customers who utilize our eiPlatform and eiConsole for X12 EDI solutions. Contact Us to have a customer service representative who will assist you with detailed pricing information.

Does PilotFish offer HIPAA Compliance Validation services?

Yes, PilotFish provides SNIP Levels 1-3 validation built into its core products (eiConsole/eiPlatform) with optional enhanced support for SNIP Levels 4-7 in its eiSuite offering. There is also an optional external EDI code set maintenance program, as well.

Does PilotFish support LOINC code validation?

Yes, PilotFish supports LOINC codes – a subset of HCPCS codes – from the AMA and updates them quarterly.

Will PilotFish support future industry transaction standards like ASC X12?

As an X12 Preferred Partner, PilotFish supports HIPAA 5010 standards and participates in their working group. PilotFish is already working on support for the HIPAA 8020 standard.

Can PilotFish’s EDI Integration solution generate TA1, 997, and 999 Acknowledgements?

Yes, PilotFish can produce and consume TA1, 997, and 999 Acknowledgements, as well as handle all EDI HIPAA X12 transactions.

How does PilotFish handle inbound compliance checking?

PilotFish includes a comprehensive compliance checking feature that validates transactions to generate necessary acknowledgments, such as 999 and TA1. This functionality supports real-time transaction processing, meeting the stringent compliance needs of our clients. See SNIP 1-7 validation.

Why is EDI healthcare parsing, mapping, and validation important?

It ensures accurate and efficient exchange of healthcare information, reduces errors and rework, and improves patient care and outcomes.

What are some challenges in EDI healthcare parsing and validation?

Complexity, varying standards, changing regulations, and manual errors are some common challenges in EDI healthcare parsing and validation.

How can EDI parsing and validation improve revenue cycle management?

It can help streamline claims processing, reduce denials and rejections, and improve cash flow by reducing the time and effort required for manual data entry and reconciliation. Read our Healthcare Revenue Recovery Solution case study.

How can EDI parsing and validation improve patient safety?

It can help ensure accurate and complete patient information, reduce medication errors, and improve care coordination and communication among healthcare providers.

What are some best practices for EDI healthcare parsing and validation?

Standardization, automation, continuous monitoring, and regular updates are some best practices for EDI healthcare parsing and validation.

What role does technology play in EDI healthcare parsing and validation?

Technology such as EDI software or middleware, artificial intelligence, and machine learning can help automate and improve the accuracy and efficiency of EDI healthcare parsing and validation processes.

What are some common errors that can occur during EDI parsing and validation?

Missing data, incorrect data formats, and invalid codes or values are some common errors that can occur during EDI parsing and validation.

How can EDI parsing and validation help with supply chain management in healthcare?

It can help streamline ordering, delivery, and payment processes, reduce errors, and improve visibility and transparency in the healthcare supply chain.

What is the role of HIPAA in EDI healthcare parsing and validation?

HIPAA sets standards for the secure and confidential exchange of healthcare information and requires compliance with specific rules and regulations for EDI data exchange.

How can EDI parsing and validation help with population health management?

It can help identify and analyze healthcare data at the population level, track outcomes and trends, and support preventive care and disease management initiatives.

How do you map and validate EDI 837 claim transactions to a database using an integration engine?

An Integration engine, or interface engine, allows you to send and receive messages, convert them to XML or another common format, validate them and map the contents of the EDI 837 transaction to a database. You can also create and generate the EDI 999 acknowledgment. To see this process in action with PilotFish’s Integration Engine watch the EDI 837 Claims Processing Integration video.

EDI 837 Data Integration with the eiConsole

EDI 837 Claim Data Integration

What tool parses EDI 837 and EDI 835 data to an SQL database?

Pilotfish’s eiConsole Interface Engine can configure interfaces to parse EDI 835 and EDI 837 messages and transform them into SQL inserts. Read more about X12 EDI Parsing.

Can the eiConsole for X12 by PilotFish map EDI 837, EDI 278 and other transactions to FHIR resources?

Yes, the PilotFish Mapper in the eiConsole for X12 can map any X12 or EDI transaction to any target transaction, resources such as FHIR, and API’s. The Data Mapper can also connect and map directly to SQL database tables.

How do you build EDI 270 transactions?

In the PilotFish Data Mapper, EDI messages can be graphically constructed into specific XML representations that the EDI Transformation Module can then convert into properly structured EDI messages.

Does PilotFish support managing customer payment information?

Yes, PilotFish facilitates the handling of customer payment details using the X12 EDI format, which is commonly employed for processing claims including payment transactions. See EDI Claims Payment Workflow for EDI 837, 835, 275, 276, 277, 999, etc.

Can PilotFish handle both medical and pharmacy (Rx) benefit eligibility verification?

Yes, PilotFish is equipped to manage both medical benefit eligibility and pharmacy benefit eligibility (typically part of the X12 EDI 270/271 sets or any other X12 transaction). Our platform includes robust EDI validation tools and offers specialized expertise in clinical transaction processing.

What application software converts XML to EDI and EDI to XML?

PilotFish eiConsole’s graphical drag & drop Data Mapper component. The Data Mapper is a graphical editor used to generate the XSLT transformations that transform the data format to any other data format. PilotFish provides a unique, robust triple-pane paradigm that supports mappings of any length and any complexity. Mapping remains graphically functional throughout.

Data Mapper – Drag & Drop

Data Mapper – Drag & Drop

What software handles both batch and real-time X12 EDI transaction processing?

PilotFish can be configured to handle both batch and real-time processing of X12 EDI over a multitude of different protocols.

How can I integrate different data formats like HL7, EDI and FHIR into a database?

Interface Engines integrate different data formats to target systems by transforming them into a common format and then routing the data into the database. Watch the PilotFish Data Analytics & Reporting Video to see this demonstrated.

HL7, EDI & FHIR Data Integration for Reporting & Analytics

HL7, EDI & FHIR Data Integration for Reporting & Analytics

How do you ingest X12 files and export them to a flat file?

PilotFish software supports an array of EDI ingestion methods including AS2, (S)FTP and local files. From there, the EDI messages can be parsed into a common format that can be converted to an XML or flat file format.

Can PilotFish’s tools handle both data conversion from CSV, XLS/Excel, or TXT to EDI 834 and the reverse process, i.e., from EDI 834 to CSV?

Absolutely. PilotFish’s integration tools are designed to support bidirectional data conversion. You can seamlessly convert data from various formats (e.g., CSV, XLS/Excel, TXT) to the EDI 834 format for Benefit Enrollment and Maintenance. Moreover, you can efficiently reverse the process, converting EDI 834 data back to CSV format. This flexibility is invaluable for technical users with diverse data interchange requirements. Watch our EDI 834 Conversion Video.

Can you process EDI and HL7 messages?

Yes, we can process EDI, HL7 and other data standards such as FHIR, JSON XML CCD/CDA, NCPDP, DICOM, flat files, fixed length files, PDF, CSV and more.

How can I transform data types from an Excel CSV to ASC X12 5010 EDI submissions through our clearinghouse and to payers?

The PilotFish platform can handle CSV to EDI transformations. These transactions can then be written to a database or sent to your clearinghouse or both. Watch this HL7 & EDI to DB/Web Services demo video for a quick demonstration.

What is PilotFish’s External HIPAA Code Set Maintenance Service?

PilotFish’s service is dedicated to maintaining HIPAA-mandated code sets such as CPT, ICD-10, and NCCI MUEs. It ensures healthcare systems are up-to-date and compliant with the latest changes in medical coding, reducing the risk of errors and minimizing administrative burdens. Our service streamlines the complex update process, safeguarding the efficiency of healthcare operations. For details, visit our External Code Set Maintenance page.

How does PilotFish ensure regulatory compliance with its code set maintenance service?

PilotFish’s service proactively manages the HIPAA code sets, including CPT, ICD-10, and NCCI MUEs, by implementing updates. This ensures that your organization’s billing and clinical coding practices remain compliant with evolving healthcare regulations. By handling the intricacies of code set maintenance, we help your organization avoid non-compliance risks and stay aligned with industry standards. Discover the full scope of our compliance solutions on our External Code Set Maintenance page.

What code sets does PilotFish’s external code set maintenance cover?

PilotFish’s maintenance service includes 49 vital code sets to support your healthcare operations, including CPT (Current Procedural Terminology), ICD-10 (International Classification of Diseases, 10th Revision), and MUE (Medically Unlikely Edits). These are essential for billing and regulatory compliance. Learn more.

After successful validation, can I forward the original 271 or 270 EDI document without converting it back into XML?

Absolutely. With PilotFish, you have the flexibility to retain a copy of the original EDI document. This is achieved through transaction attributes in our platform. Therefore, you can store the original EDI message as an attribute and easily reference it as required, eliminating the need for reconversion.

How does EDI healthcare data conversion improve revenue cycle management?

EDI healthcare data conversion can improve revenue cycle management by reducing claim denials, accelerating payment cycles, and improving billing accuracy and efficiency.

How does EDI healthcare data conversion enable population health management?

EDI healthcare data conversion can enable population health management by providing real-time access to patient data from different sources, enabling predictive analytics, and improving care coordination and patient outcomes.

How does EDI healthcare data conversion help with population health analytics?

EDI healthcare data conversion can provide accurate and timely patient data for population health analytics, enabling healthcare organizations to identify trends, monitor outcomes, and improve care quality and efficiency.

How does EDI healthcare data conversion enable interoperability between different healthcare systems and stakeholders?

EDI healthcare data conversion enables seamless data exchange between different healthcare systems and stakeholders, including providers, payers, patients, and government agencies.

How can healthcare providers ensure data accuracy during EDI healthcare data conversion?

Healthcare providers should implement data validation and reconciliation processes, use standard code sets and data formats, and conduct regular testing and quality assurance to ensure data accuracy. See SNIP Validation.

How does EDI healthcare data conversion support value-based care and alternative payment models?

EDI healthcare data conversion enables real-time data exchange and interoperability between providers and payers, enabling them to collaborate on value-based care initiatives and alternative payment models that incentivize quality and efficiency.

Can PilotFish handle scanning and capturing data from paper claims?

While PilotFish itself does not directly scan claim documents, it can seamlessly integrate with services that offer Optical Character Recognition (OCR) capabilities to create EDI 837 claim files or other data formats.

How does EDI integration work?

Interface engines integrate EDI data formats to target systems by transforming them first into a common format. EDI mapping is how the EDI source data is mapped from a common form to related target data fields, converted and output as XML, Excel, JSON, other EDI formats and other specified formats.

Can PilotFish utilize a simple code script for universal file type validation and feedback?

Certainly. PilotFish’s versatile validation capabilities allow for a straightforward script to manage the validation of any file type. This efficient code extracts key details such as the X12 version and transaction type from EDI documents to ensure accurate SNIP validation.

How can I validate an X12 EDI 270 without transforming it in PilotFish software?

To validate an X12 EDI 270, or any other X12 transaction within PilotFish, it’s necessary to convert the EDI to XML because the validation is performed in XML format. This transformation is achieved effortlessly using the EDI transformation module.

Does PilotFish offer validation at both the file and transaction set or claim level?

Yes, with PilotFish, you’re able to perform validation not just at the file level but also at specific levels such as transaction set or claim level. You can customize the validation rules and use data mapping to achieve this.

Can I bypass specific validation rules in PilotFish?

Certainly. PilotFish offers the flexibility to omit select validation rules as per your requirements. We offer SNIP validation 1-7.

Can I perform validation at a particular repeating element level within a transaction set in PilotFish?

Absolutely! With PilotFish, you can not only validate at specific repeating element levels within a transaction set but also segment transactions based on the outcomes of these validations.

Is there a way to create a real-time EDI validation service using an API?

Yes, you can create a real-time EDI validation service using the software’s API capabilities. You can set up a RESTful Web Service Listener to receive EDI messages, initiate validations and return error diagnostics in JSON format seamlessly.

Can I create an EDI inquiry file (270/271) from Excel data?

Yes, as long as the XLS file has all the data needed to generate X12 EDI 270/271 transactions, you can use PilotFish to map the Excel fields to the 270/271 fields using XML and XSLT. Then you can transform the XML to EDI. You can do this for any X12 transaction. Video: Converting CSV to EDI 834.

What tool will validate EDI SNIP 1 and 2 files and debug exceptions in those files coming from our customers?

We recommend the eiConsole with the X12 EDI bundle (the bundle can be selected when you download the software or a free trial). The eiConsole can handle SNIP Type 1-7 (SNIP Level 1-7) validations.

Is PilotFish capable of generating email acknowledgments for transactions like 277CA, 999 and TA1?

Yes, PilotFish can send email acknowledgements, or send something as a part of an email body. 277CA and 999 and TA1s are part of the EDI standards, which PilotFish fully supports.

Why should I subscribe to PilotFish’s External HIPAA Code Set Maintenance Service?

Subscribing to PilotFish’s External Code Set Maintenance ensures your organization has the most current code sets from 49 authoritative sources. This service simplifies the complex process of code set updating. PilotFish’s solution provides a streamlined, reliable approach to maintaining your integration platform’s compliance and efficiency. Learn more about External Code Seet Maintenance.

What kind of validation does PilotFish provide for EDI transactions?

PilotFish offers comprehensive EDI validation up to SNIP level 5, ensuring structural integrity, code set accuracy, and business rules compliance.

Does PilotFish support current national claims routing functionalities? For example, a lookup query for optimized routing.

Yes, PilotFish can do a lookup query with its software, which is optimized for routing an EDI 837 claims transaction set. The EDI 837 transaction set contains detailed information about the medical services provided, including patient information, service dates, codes for procedures and diagnoses, and billing information. The query determines the correct destination for each claim based on the patient’s insurance information. PilotFish can send an EDI 835 with information about the payment, adjustment, denial and other claim details.

Can PilotFish execute web service callouts, such as for claim ID validation?

Yes, PilotFish can do web service callouts to validate data from external sources. PilotFish can interface with any API to perform actions such as resource retrieval through web service or HTTP post.

Does PilotFish support data splitting such as ISA or claim level splitting for SNIP level validation? For example, good vs bad claim level or an enrollment level split.

Yes, PilotFish has customers that require splitting based on some level of validation. For instance, in an 837 file with multiple claims, PilotFish can separate the data into two files, allowing the valid file to continue processing if the other encounters issues.

Can PilotFish validate claims based on the Line of Business (LOB), profiles or regions?

Validating claims by Line of Business, profiles, regions, or other business-specific criteria is supported by PilotFish under SNIP Level 7.

Can PilotFish be configured with unique SNIP level settings for claim edits by Line of Business (LOB) profiles and regions?

Yes, PilotFish can create tailored rules for SNIP level settings based on requirements provided as long as the logic details are supplied.

Is PilotFish capable of configuring Trading Partners by region and transaction type?

Yes, PilotFish can establish a Trading Partner table customized by region and transaction type.

Can PilotFish handle large volumes of daily transactions such as EDI 270/271?

Yes, for instance, we have a PilotFish client with large transaction requirements that is processing 200,000 EDI transactions per month in real-time, including EDI 270, 271, 999, and some 276 and 277s. These transactions are also validated through the SNIP Validation Processor supporting SNIP Levels 1-7.

Can PilotFish support and implement code set upgrades, including medical code sets, in a timely manner?

Yes, PilotFish utilizes its own eiPlatform to automatically retrieve and integrate new HIPAA EDI Code Sets as soon as they are released. For code sets that are only available with an email notice, these are downloaded and added to the EDI code set database within 24 business hours.

Does PilotFish provide automatic generation and sending of EDI 999 or EDI 997 responses?

Yes, PilotFish features a processor that automatically generates and sends EDI 999/EDI 997 responses upon transaction rejection. Additionally, PilotFish offers a range of error handling options to manage exceptions beyond these scenarios.

If you have any additional questions or require further assistance, please don’t hesitate to contact our customer support team. Click on the button or jump into a chat.

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.
HL7®, HEALTH LEVEL SEVEN®, CCD®, CDA®, and FHIR® are trademarks of Health Level Seven International.

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