(EDI) Electronic Data Interchange and HIPAA
Under HIPAA the administrative simplification portion of the law, any covered
entities engaging in one more the identified electronic transactions must comply with the standards
for the transaction.
The standards for HIPAA covered entities were created by the American National
Standards Institute (ANSI.) Health care organizations must use the ANSI ASC X12N standard format
whenever exchanging EDI.
What are Implementation Guides?
Organizations who must adopt the ANSI standards develop implementation guides to
help covered entities and business partners. The guides have complete details for HIPAA
implementation. The guide provides detailed instructions on how data should be moved
electronically. Software vendors, billing services, payers, and clearing houses rely on these
documents to become compliant with the electronic transactions and code sets as required by
There are four types of HIPAA claims that are described in the implementation
ASC X12N 837: Professional Guide - UB92 claim forms after processing are converted to
ASC X12N 837: Institutional Guide - HCFA claim forms after processing are converted to
ASC X12N 837: Dental Guide
NCPDP: Retail Pharmacy Transactions Guide
Can I still submit on paper?
Providers may still file claims on paper. Once you decide to submit your
transaction electronically, it must be in HIPAA compliant format. Health plans may decide to
accept only electronic transactions. If this is the case, you as the provider will have to use a
clearinghouse or implement HIPAA compliant billing software.
There are two type code sets as referred to by HIPAA as either medical or
non-medical codes. These codes are used to encode data elements such as medical diagnosis or
procedure codes. The major codes are ICD-9CM, NDC, CDT, HCPCS and CPT codes. All these codes can be
placed in tables and compared to entered data to ensure accuracy when keying or OCR’ing data from
Imagine having all your paper claims be delivered to you as HIPAA compliant
ANSI X12 837 transaction sets. You can have all you paper claims be submitted to you as EDI
claims. We use custom coders to work with your IT staff to make sure your gateway can import
the X12 837 files we create for you. All we need is your implementation guide
to get started. Your submitters still get to submit on paper but you don't have to look at it