Accelerate Your Business with EDI Healthcare Review and Response Service

Healthcare constantly evolves, making effective data management crucial. Electronic Data Interchange (EDI) has become key in healthcare. It changes how we handle and exchange healthcare information. This introduction highlights EDI’s role and importance in the healthcare industry.

EDI is the electronic sharing of healthcare data in a set format. It moves us from paper to digital in managing medical data, claims, and payments. EDI in Healthcare is more than digitizing paper records. It changes how we handle healthcare information.

EDI’s impact is clear in claim processing. Where paper claims took weeks, EDI does it in days or hours. This speed is vital. It affects patient care and how healthcare operations run.


Why EDI Matters in Healthcare Business?


EDI is crucial in healthcare for many reasons:


  • Speed: EDI speeds up healthcare transactions. It’s 70% faster than old methods. Quick information can save lives.
  • Cost Savings: EDI saves money. It costs less than manual processes. Healthcare providers can save around $1.49 per transaction.
  • Accuracy: Manual data entry often has errors. EDI reduces these mistakes. It ensures better patient records and billing. Manual error rates are about 10% but less than 1% with EDI.
  • Regulatory Compliance: Healthcare has strict rules. EDI helps meet these standards. For instance, it aligns with HIPAA requirements.
  • Better Patient Care: EDI leads to faster care. Quick claims and authorizations mean patients get help sooner. This improves health outcomes.

EDI in healthcare is more than a tech update. It’s a strategic tool that boosts operations and patient care. It uses technology to improve healthcare results.

EDI is a major force in healthcare. It’s not just for operations. It’s reshaping how we manage healthcare information. EDI sets new standards for efficiency, accuracy, and patient-focused care.


Why is HIPAA Vital?


HIPAA permits individuals to purchase any type of health insurance, especially after losing coverage from their employer. It leverages only the eligible, with pre-existing health conditions to buy insurance sponsored by health insurance companies and employers.




HIPAA is a vital component for issuing and acquiring health care insurance and also establishes national standards for Electronic Healthcare Transactions. It improves the entire healthcare industry’s system through implementing the set standards.

HIPAA ensures that data transmission must run under a universal set X12 protocol. The ANSI x12 EDI protocol defines the roadmap of sending and formatting data. Healthcare providers or financial institutions selling insurances and healthcare plans are bound to follow these set standards.

Integrating EDI with HIPAA standards ensures an efficient health care system while reducing the overhead burden of administrative management. Additionally, care providers using EDI X12 tend to have increased profitability and accessibility of healthcare information and documents.

Typically electronic healthcare transaction sets requiring EDI X12 format are segregated under –

  • Benefit Enrollment and Maintenance – 834
  • Healthcare Eligibility/Benefit Inquiry – 270
  • Healthcare Claims – 837
  • Healthcare Claim Payment/Advice – 835
  • Healthcare Payroll Deducted & other Group Premium Payment – 820
  • Healthcare Eligibility/Benefit Response – 271
  • Healthcare Claim Status Request – 276
  • Healthcare Claim Status Notification – 277
  • Healthcare Service Review Information – 278


From March 2012, the healthcare providers were mandated to have a 5010 compliant version of HIPAA EDI standards, which includes claim status, referrals, claims, remittances, and eligibility.

This article is focused on the EDI transaction set 278 – Healthcare Service Review Information and how data is electronically transmitted. We will also highlight the need for outsourcing EDI in the healthcare industry for 278 standards.


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Definition & Purpose of EDI 278


As aforementioned, every transaction set follows HIPAA standards. 278 is one among many HIPAA standard transaction sets, which is meant to request for reviewing patient’s data, diagnosis, or any treatment data. This transaction set is also meant to report an outcome for a review. For instance, through the 278 transaction set – a healthcare provider can request patients for their healthcare certificates, or a hospital can send a patient’s discharge notice.

The review and response transaction set – 278 can either be sent one-way or two-way (sent/received). In order to determine accuracy in sending or retrieval of data, utilization management organizations (UMO) play a vital role. The UMOs are usually identified as insurance companies, PPOs, and others.

Regardless of the fact that EDI supports multiple member transactions, it is recommended to send an individual 278 for each patient and event. The 278 transaction set can be used for the following categories –

  • Completion Notification
  • Information Copy
  • Advance Notification
  • Change Notification


Process Flow of the EDI 278


The process begins by-

  • Submission(trading partner) of the EDI 278 requests.
  • EDI identifies the request and validates it to generate a 999 response file.
  • Any EDI integration services in the organization have a UMI process that generates a response file for 278 requests raised.
  • When the backend system generates the 278 response, it is sent to EDI for validation.
  • EDI then validates the file received from the backend and sends a 278 response to the trading partner.


For Reference –


Before integrating a 278 transaction set for organizations, they are thoroughly tested by the EDI service providers to ensure smooth flow of request & response transactions. Testing identifies possible connectivity failures, such as –

  • If the partner is unable to receive a response.
  • If the partner wishes to resubmit the inquiry.


Choosing the right EDI service provider ensures a perfect EDI healthcare solution that can connect with your system and comply with your business requirements & culture. They will also ensure that the data transmission undergoes safely.


EDI 278 Transaction Set-

Implementation Checklist


A complete process is followed by the outsourced team of EDI before integrating it into any organization’s system. The testing process follows the below mentioned steps –

  • The request is sent for any XYZ reason from the guest partner to another, filing the mandates.
  • A dedicated software development team is assigned to check every step, hence work side-by-side to underline the loopholes or failures during testing.
  • The guest partner is given proper instructions that include relevant information to fill and follow.
  • The development team then reviews the data entered by the guest trader and checks whether the entered data is correct. If there is an error in the data submission, the guest partner is asked to resubmit the information.
  • When the request is retrieved appropriately, the response file is prepared and sent back.
  • The response is reviewed and tested for approval.
  • When noted everything is as per the process, it is then declared as successful completion.

When A1 request for authorization is raised from the trading partner or healthcare provider, the EDI healthcare service response would look like –






If the process somehow fails, it will look like this –





EDI 278 – Request and Response Examples


A clear transmission EDI 278 request transaction process explanation can be seen below –


  • ST*278*0001*005010X217~

The 278 is the transaction set with a control number #0001 and a reference protocol is 005010X217.


  • BHT*0007*11*C64374*20050502*1102*16~

The 0007 is a structure for a response, such as information receiver, subscriber, event, services, etc). The submitter transaction identifier C64374 is returned through the UMO system. Further information regarding response is denoted through the BHT value of 16.

There are different hierarchical levels (HL) followed by EDI in 278 transmission format for request/response review. These hierarchies can be identified as different partners, such as Insurance company, submitting provider, subscriber, and the patient. The below example highlights the request raised for the patient’s appointment and diagnosis of ailment.


  • HL*1*2*EV*2~

The HL count is 1 here with a subordinate to HL 3, which is the parent hierarchical level. The EV code identifies the patient event and subordinate levels or children. In this case, this HL has children as the value represents 2.


  • TRN*2*112589*9849047591~

This is the trace number assigned by the care provider for UMO to respond to the request through the number.


  • UM*SC*I*3*11:B~

This line of code represents the requested initial consultation service. Here Dr. Wan has raised a request for an appointment for a patient with Dr. Lee at Dr. Lee’s office.


  • HCR*A1*AUTH0001~

This line of code dictates Washington Digital approved the referral & offers a certification number.


  • DTP*AAH*RD9*19050303-19050403~

The line of code explains that the insurance company shows the range of date for possible consultation.


  • HI*BF:41090:D8:20050430~

This code displays that acute disease has been diagnosed of the patient.


  • HSD*VS*2~

Dr. Wan requested two visits.


  • NM1*SJ*2*LEE*ANDREW****31*991001356~

The event provider of the patient is Andrew Lee, and his social security number is 991001356.


  • PER*IC**TE*5474892021~

Dr.Lee’s contact number is 5474892021


  • SE*16*0002~

This line of code explains the number of segments and control number.


This is a simple example of the EDI 287 transaction set; however, when you add multiple members to EDI you will have numerous requests to which responding at a time becomes challenging. Moreover, sending an adequate response to the requisite request is another struggle. Here is where you can have the assistance of an outsource or managed EDI service provider.


Should You Outsource Your EDI Healthcare Services?


Outsourcing EDI can benefit business operations in many ways. Let’s understand how outsourcing can truly assist in business growth.


Streamlined Processes


In 2001, Owens Corning was bewildered at calculating the amount spent on handling paper invoices, orders, and acknowledgment. It is not a surprise that many companies cannot break the chain of using paper instead of electronic data interchange (EDI). When the renowned Owens Corning switched its manual-paper work to EDI, he realized the lack of requisite infrastructure and staffing skills. Infrastructure is easy to obtain but finding a qualified resource was a struggle. Instead of hand-picking the staff, they outsourced their entire EDI.

The result was – adequate infrastructure for EDI was sought, compliance needs were met, staffing solutions & training were no more a headache, the latest tools & technology could be integrated, migration of manual work to the cloud based EDI for effective outcome and security was seamless. All these streamlined enhanced their efficiencies and increased their process to reach vendors or even process a transaction set on their own.


Comprehensive Solution


Outsourcing EDI managed services are cost-effective and efficient than employing an in-house team. It is a myth that outsourced EDI service providers charge exorbitantly for their time and efforts. Instead, you can pick a model that suits your budget as well as meets your objectives.

Moreover, the level of experience that you get from an outsourcing provider is unmatchable. The team entirely handles the processes so that the organizational head can focus on other crucial work, such as mapping and defining processes.

Outsourcing EDI providers also evaluates existing infrastructure to comprehend what’s lacking. Whether it is a single network translator or an entire infrastructure, they make your EDI processes faster and efficient.


Agile, Effective & Web-Based


As per Giga Information Group, B2B EDI integration is growing at 10%-15% each year. Most importantly, the small firms are leading towards this adoption more than any.

Large organizations handling a pool of processes each day every minute need a robust and agile solution that can handle manual entry. The Healthcare industry that relies on manual processes can lead to the delay of ailment diagnosis of the patient, further delaying the treatment.

Outsourcing EDI solutions can seamlessly reduce the need for expensive infrastructure as well as internal IT consultation services.

Associating with the right service provider can help you quickly comprehend requests and align with the care providers for accurate and quick responses.


Maximizing the Benefits of EDI in Healthcare


Electronic Data Interchange (EDI) has changed healthcare for the better. It makes business processes more efficient, accurate, and cost-effective. To get the most out of EDI healthcare, we must focus on strategies that improve return on investment (ROI) and have clear ways to measure success.


Strategies to Boost ROI with EDI


EDI healthcare aims to make data exchange smoother and cut costs. To fully benefit from EDI, healthcare organizations should:

  • Integrate with Current Systems: EDI should fit well with existing healthcare systems. This smooth integration coordinates patient information and billing efficiently. For example, EDI 834 services manage benefits enrollment and can greatly simplify benefits management.
  • Training and Education: Proper staff training is key. It reduces mistakes and speeds up processes, leading to better ROI.
  • Continuous Monitoring and Updates: EDI needs regular checks and updates. This ensures it stays efficient and meets healthcare’s changing needs.
  • Data-Driven Decisions: EDI provides valuable data. This data helps healthcare providers spot trends, plan for the future, and use resources wisely.


Measuring EDI Success: Key Performance Indicators


To see how well EDI is working, we look at specific Key Performance Indicators (KPIs):

  • Error Rate Reduction: A major KPI is how much EDI cuts down errors. Lower errors mean cost savings and better patient care.
  • Processing Time: How fast EDI processes transactions shows its efficiency. Faster processing leads to quicker billing and better cash flow.
  • Cost Savings: EDI should save money. It cuts down on paper, postage, and admin work.
  • Patient Satisfaction: A better EDI system means happier patients. It leads to faster claims and fewer mistakes.
  • Compliance Rates: In healthcare, following rules like HIPAA is crucial. Good EDI systems help you stay compliant, avoiding penalties and legal issues.


EDI healthcare, especially EDI 834 services, is a vital tool. When used well, it can boost efficiency and ROI. By focusing on effective strategies and tracking KPIs, healthcare organizations can maximize EDI’s benefits. As a result, this leads to better patient care, lower costs, and smoother operations. As healthcare evolves, EDI will remain a key part of this change.


Ensuring Security & Compliance in EDI Transactions


Security and compliance are crucial in healthcare’s Electronic Data Interchange (EDI). As technology grows and digital transactions increase, securing and complying with EDI, especially for providers like EDI 834 services, becomes more complex. They handle sensitive patient enrollment data.


Strengthening EDI Security


EDI healthcare security is complex. It needs to adapt to new threats and tech changes. Key security measures include:

  • Encryption: This makes data unreadable to unauthorized people. Healthcare EDI uses strong encryption, like AES 256-bit, to protect data during transmission.
  • User Checks: Ensuring only the right people access EDI data is important. Methods like two-factor authentication (2FA) add extra security.
  • Regular Security Checks: Regular audits and tests find and fix security weaknesses. This keeps EDI systems safe.
  • Data Checks: Keeping data accurate and unchanged is vital. Techniques like checksums and digital signatures help detect data tampering.
  • Safe Cloud Storage: Many EDI services use cloud storage. It must follow healthcare laws, like HIPAA in the U.S.


Keeping Up with Compliance


Compliance in healthcare changes often. EDI systems need to keep up:

  • Ongoing Learning: Staff must stay updated on new laws and rules. Regular training is essential.
  • Flexible Systems: EDI systems should quickly adapt to new regulations. This helps healthcare providers stay compliant without interrupting their work.
  • Expert Collaboration: Working with legal and compliance experts helps EDI systems stay current and ready for future changes.
  • Policy Updates: Regularly updating EDI policies ensures they match current regulations and best practices.
  • Detailed Records: Keeping detailed records of all EDI transactions is important for compliance. Audit trails help track any issues and prove compliance during inspections.


Security and compliance in EDI healthcare are ongoing and dynamic. It needs advanced security methods, continuous learning, and a proactive approach to regulation changes. As digital data exchange grows, healthcare EDI and EDI 834 service providers must focus on these areas to protect patient data and maintain system trust.


Training and Support for EDI Systems


Electronic Data Interchange (EDI) in healthcare is a big step toward better efficiency and accuracy. But, how well EDI works depends a lot on the training and support staff get. Studies show that comprehensive training can increase staff proficiency in EDI usage by up to 50%. Let’s explore the best ways to train staff and keep EDI systems in good shape.


Best Ways to Train Staff in EDI


Good training is key to maximizing EDI healthcare. Here are some top practices:

  • Customized Training: Each healthcare group differs. Training that fits their needs helps staff use EDI well in their work. For healthcare EDI, include real-life examples they might see.
  • Hands-on Practice: Learning by doing is effective. Let staff try out the EDI system. This builds confidence and skills.
  • Ongoing Learning: EDI and rules change over time. Continuous learning, with updates and refreshers, keeps staff up-to-date.
  • Helpful Resources: Give staff easy-to-use materials, like guides, online help, and FAQs. This makes it easy for them to find answers quickly.
  • Feedback Loop: Let staff share their EDI experiences. This can show where training needs to improve.


Keeping EDI Systems Running Well


After setting up EDI, ongoing support and maintenance are crucial. Here’s how to do it:


  • Dedicated Team: A team focused on EDI support can solve problems fast. They should know both EDI tech and healthcare.
  • Regular Updates: EDI software needs updates to stay current and safe. Plan these updates regularly.
  • Proactive Checks: Don’t just wait for problems. Regularly check and review the EDI system to stop issues before they start.
  • User Feedback in Improvements: Use staff feedback to improve the EDI system. This keeps it useful and up-to-date.
  • Plan for Emergencies: A solid plan for emergencies, like system failures or data breaches, is vital. It should have clear steps to minimize disruption.

Training and support are crucial for EDI’s success in healthcare. With proper training, healthcare workers can fully use EDI. This leads to better work, accuracy, and patient care. Ongoing support and care keep the systems reliable for the long haul.


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Electronic Data Interchange (EDI) has greatly changed healthcare. It makes processes smoother and operations more efficient. EDI healthcare is a journey with important steps that have changed how healthcare providers and EDI services collaborate. EDI improves administrative work and positively affects patient care.


One big change with EDI is better healthcare data management.
  • EDI makes data sharing quicker and more accurate. Before, methods were slow and often wrong. Now, fast digital communication has improved how healthcare providers work. This leads to better services for patients and more efficient operations.
  • EDI also cuts costs. By automating data exchange, it saves money on administration. Research shows that healthcare providers save about $1.49 per claim with EDI. For big organizations, this means saving millions each year. This cost-effectiveness lets them spend more on patient care and research.
  • EDI boosts security and compliance in handling patient data. With rules like HIPAA, EDI systems offer a safe way to deal with sensitive information. This is key to keeping patient trust and protecting their details.


EDI healthcare has already made a big impact and will continue to shape its future. For healthcare providers, using the latest EDI tech is essential to stay ahead and offer the best care.

Looking forward, EDI’s potential in healthcare is huge. If you haven’t started using EDI, now is the time. The benefits are clear: more efficiency, cost savings, better security, and improved patient care. 




What are the steps to ensure HIPAA compliance in EDI?


To align EDI with HIPAA, do the following:

  • Secure Systems: Use strong encryption and safe networks for EDI data.
  • Regular Training: Keep staff updated on HIPAA and its relation to EDI.
  • Audits: Regular checks ensure EDI meets HIPAA standards.
  • Keep Records: Document all EDI transactions as compliance proof.


How do you choose between in-house and outsourced EDI solutions?


Decide based on:

  • Resources: In-house needs more setup and upkeep resources.
  • Expertise: If lacking in-house EDI skills, outsourcing might be better.
  • Control and Customization: In-house gives more personalization and control.
  • Cost: Compare the long-term expenses of both options.


What are the latest innovations in EDI technology for healthcare?


New EDI developments in healthcare include:


  • Cloud-Based Solutions: They’re scalable and adaptable.
  • AI Integration: For smarter analytics and decision-making.
  • Better Security: Using technologies like blockchain for safer data.
  • Mobile EDI: Access healthcare EDI anytime, anywhere.


How do you measure the success of an EDI implementation?


Measure it through:

  • Fewer Errors: Big drop in data mistakes.
  • Better Efficiency: Quicker processes and less admin work.
  • Cost Reduction: Lower administrative expenses show success.
  • User Feedback: Positive reactions from staff and patients.


What are the future predictions for EDI in the healthcare industry?


Expectations for EDI’s future in healthcare:

  • Wider Use: More providers will use EDI for efficient data management.
  • Improved Sharing: Better data exchange among different health systems.
  • Patient-Focused: EDI evolving to support more patient-centered care.
  • Tech Integration: Ongoing merging with tech like AI, IoT, and blockchain.