(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 HIPAA.

There are four types of HIPAA claims that are described in the implementation guides:

  • ASC X12N 837: Professional Guide - UB92 claim forms after processing are converted to this format
  • ASC X12N 837: Institutional Guide - HCFA claim forms after processing are converted to this format
  • 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 paper.

Claims Processing

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 anymore. 


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