HIPAA EDI (Health Insurance Portability and Accountability Act Electronic Data Interchange) - Document Structure

HIPAA EDI (Health Insurance Portability and Accountability Act Electronic Data Interchange) sets standards for electronically exchanging healthcare information. These standards facilitate the secure and efficient exchange of patient information, billing details, and other healthcare-related transactions between providers, payers, and clearinghouses.

HIPAA EDI transactions are primarily based on the ANSI ASC X12 standard, and the document structure is defined by specific transaction sets, each assigned a unique identifier. Some of the most commonly used HIPAA EDI transaction sets include:

• 837: Health Care Claim (Professional, Institutional, Dental)
• 835: Health Care Claim Payment/Advice
• 270/271: Health Care Eligibility Inquiry and Response
• 276/277: Health Care Claim Status Request and Response
• 278: Health Care Services Review Information
• 834: Benefit Enrollment and Maintenance

1. General Structure of HIPAA EDI Documents

HIPAA EDI documents follow the ANSI ASC X12 format, which consists of segments, elements, and loops:

• Segments: The basic unit of information in an EDI document, representing a specific piece of information (e.g., patient information, claim amount).
• Elements: Data components within a segment, separated by a delimiter (often an asterisk *).
• Loops: Groups of related segments that repeat together to capture related sets of information.

Each EDI document starts with an Interchange Control Header (ISA) and ends with an Interchange Control Trailer (IEA). The structure includes functional groups and transaction sets within these headers and trailers.

2. Key HIPAA EDI Transaction Sets

2.1 837 Health Care Claim

Used by healthcare providers to submit claims for payment to payers. There are three types of 837 transactions:

• 837P: Professional Claims
• 837I: Institutional Claims
• 837D: Dental Claims

Example Structure of 837:

• ISA: Interchange Control Header
• GS: Functional Group Header
• ST: Transaction Set Header
• BHT: Beginning of Hierarchical Transaction
• Loop 1000: Submitter and Receiver Information
  • NM1: Name Segment (e.g., Submitter Name)
• Loop 2000: Subscriber Hierarchical Level
  • HL: Hierarchical Level
  • SBR: Subscriber Information
  • Loop 2300: Claim Information
    • CLM: Claim Information
    • DTP: Date/Time Period (e.g., Date of Service)
• SE: Transaction Set Trailer
• GE: Functional Group Trailer
• IEA: Interchange Control Trailer

Example:

ISA*00*          *00*          *ZZ*SENDERID       *ZZ*RECEIVERID     *210901*0800*^*00501*000000001*0*P*:~
GS*HC*SENDERID*RECEIVERID*20210901*0800*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*0123*20210901*0800*CH~
NM1*41*2*SENDER NAME*****46*123456789~
PER*IC*EDI SUPPORT*TE*5555555555~
NM1*40*2*RECEIVER NAME*****46*987654321~
HL*1**20*1~
NM1*85*2*PROVIDER NAME*****XX*1234567893~
N3*123 MAIN ST~
N4*ANYTOWN*GA*30303~
HL*2*1*22*0~
SBR*P*18*MED*ABC****CI~
NM1*IL*1*DOE*JOHN****MI*123456789A~
CLM*123456*500***11:B:1*Y*A*Y*I~
DTP*434*RD8*20210101-20210101~
SE*25*0001~
GE*1*1~
IEA*1*000000001~

• ISA: Identifies the sender and receiver, with control numbers and date/time.
• GS: Groups transaction sets that are related.
• ST: Marks the start of a transaction set.
• NM1: Name information (e.g., provider, receiver).
• CLM: Claim information, such as the claim number and amount.
• SE: Indicates the end of the transaction set.

2.2 835 Health Care Claim Payment/Advice

Used by payers to send payment information and explanations of benefits to providers. It includes payment details, such as what was paid and adjustments made.

Example Structure of 835:

• ISA: Interchange Control Header
• GS: Functional Group Header
• ST: Transaction Set Header
• BPR: Financial Information
• TRN: Reassociation Trace Number
• Loop 1000: Payer Identification
  • N1: Name Segment (e.g., Payer Name)
• Loop 2000: Header Number
  • LX: Header Number
  • TS3: Provider Summary Information
  • Loop 2100: Claim Payment Information
    • CLP: Claim Payment Information
    • CAS: Claim Adjustment
    • NM1: Patient Name
• SE: Transaction Set Trailer
• GE: Functional Group Trailer
• IEA: Interchange Control Trailer

Example:

ISA*00*          *00*          *ZZ*SENDERID       *ZZ*RECEIVERID     *210901*0800*^*00501*000000001*0*P*:~
GS*HP*SENDERID*RECEIVERID*20210901*0800*1*X*005010X221A1~
ST*835*0001*005010X221A1~
BPR*C*1500*C*ACH*CTX*01*123456789*DA*987654321*123456789*151231*01~
TRN*1*1234567890*9876543210~
N1*PR*PAYER NAME*PI*1234567890~
LX*1~
TS3*1234567890*20191231*1*1000~
CLP*123456*1*2500*2000*500*11*MC123456789~
CAS*CO*45*500~
NM1*QC*1*DOE*JOHN~
SE*19*0001~
GE*1*1~
IEA*1*000000001~

• BPR: Details about the payment, including amount and method.
• TRN: Trace number to link the payment with the claim.
• CLP: Claim payment information, including the claim ID and payment amount.
• CAS: Details about adjustments made to the payment.

2.3 270/271 Health Care Eligibility Inquiry and Response

• 270: Used by providers to inquire about a patient's eligibility and benefits.
• 271: Used by payers to respond to the 270 inquiry with eligibility and benefit information.

3. Common HIPAA EDI Segments

• ISA: Interchange Control Header
• GS: Functional Group Header
• ST: Transaction Set Header
• NM1: Name Information
• CLM: Claim Information
• DTP: Date/Time Period
• BPR: Financial Information
• CAS: Claim Adjustment
• SE: Transaction Set Trailer
• GE: Functional Group Trailer
• IEA: Interchange Control Trailer

4. Document Characteristics

• Standardized Format: Ensures consistent data representation, reducing errors and increasing processing efficiency.
• Loops and Segments: Allows the inclusion of complex information, such as multiple diagnoses or procedures, within a structured format.
• Delimiters: Uses specific characters (e.g., *, ~, :) to separate elements and segments within the document.
• Control Numbers: Each transaction has unique identifiers for tracking and managing the exchange of documents.