In the healthcare benefits industry, efficient and accurate data exchange is crucial for streamlined operations, and improved patient care, and in the case of TPAs, accurate billing and reimbursement Electronic Data Interchange (EDI) plays a pivotal role in facilitating seamless communication between healthcare providers, insurers, administrators, and other stakeholders.
Three specific types of EDI files, namely the EDI 834, 835, and 837, are commonly used to transmit essential information related to enrollment, payment, and claim transactions. In this blog post, we will explore these EDI file formats, their purposes, and their significance to third party administration.
- What are EDI Files?
- EDI 834: Benefits Enrollment and Maintenance
- EDI 835: Healthcare Claim Payment/Remittance Advice
- EDI 837: Healthcare Claim File
- EDI 999:Implementation Acknowledgment
- Benefits of EDI Files
- The Future of EDI Files
- What if you don’t have access to an EDI 834, 835 or 837 file and need it?
Let’s jump in.
What are EDI Files?
EDI files are electronic documents used to exchange information. Applicable for a range of industries, EDI files have revolutionized healthcare data exchange. Healthcare interoperability — the ability to access, integrate, and exchange electronic healthcare data — has shifted into top focus in recent years with the introduction of API data standards like the FHIR.
Traditionally, the exchange of healthcare data like benefits information was a paper-based, inefficient process. This heightened the risk of manual errors and served as a roadblock that slowed data exchange for healthcare benefits. With an EDI file, the process of exchanging healthcare data is made simple. Several key EDI file types empower TPAs and healthcare providers to handle benefit enrollment, payment processing, and claim submission with enhanced speed and minimized errors.
Exploring Key EDI File Types
EDI 834: Benefits Enrollment and Maintenance
The EDI 834 file format is a benefits enrollment and maintenance document used by a multitude of organizations, from employers to TPAs to insurance agencies. This document allows the enrollment of members directly into a benefit plan, and it must abide by HIPAA 5010 standards. For TPAs, this file is most often used to add, remove, or update a member’s enrollment information.
Want to dive deeper into this file format? Read more in our EDI 834 file deep dive to learn more about its unique advantages, other formats of enrollment data files, and importantly for TPAs: what to do if EDI 834 is not available.
EDI 835: Healthcare Claim Payment/Remittance Advice
The EDI 835 file format is used for transmitting information related to healthcare claim payments and remittance advice. It provides details about payments made by insurance companies or payers to healthcare providers for services rendered. The file includes payment amounts, adjustment codes, reason codes, and information about denied claims.
Healthcare providers use the EDI 835 file to reconcile payments, identify any discrepancies, and ensure accurate financial records. This electronic remittance advice helps streamline the payment process, minimize manual effort, and reduce errors associated with paper-based payment transactions.
EDI 837: Healthcare Claim File
The EDI 837 file format is designed for transmitting healthcare claim information from healthcare providers to insurance payers. It contains comprehensive details about the services rendered, including patient demographics, diagnosis codes, procedure codes, service dates, and billed amounts. Unless you are a TPA operating as a payer, you’re unlikely to encounter an EDI 837 file.
There are three subtypes:
- EDI 837P: For outpatient care, includes medical and vision
- EDI 837I: For institutional care like a hospital stay or emergency room visit
- EDI 837D: For all types of dental care
An EDI 837 file includes
- Patient information, such as name and date of birth (DOB)
- The reason for the patient visit
- The services rendered or treatment provided
- Total cost of the treatment
The EDI 837 file plays a critical role in streamlining the claims submission and processing workflow. It eliminates the need for manual claim form filling, reduces errors, accelerates claims processing, and expedites reimbursement for healthcare providers. Payers can efficiently process claims using automated systems, ensuring accurate adjudication and prompt payment.
EDI 999: Implementation Acknowledgment
An EDI 999 is a required response to any of these file types. It confirms the file was received and includes additional information about if the 834, 835, or 837 had errors. The acknowledgment could indicate one of three results
- Accepted (A)
- Rejected (R)
- Accepted with errors (E)
It is often the case that there is an acknowledgment of receipt but it doesn’t always mean the transaction will be processed (in the case of rejection).
Benefits of EDI 834, 835, and 837 Files
EDI files significantly reduce data entry errors, ensuring that accurate information is transmitted between parties. This promotes efficient claims processing, reduces delays, and minimizes the need for manual intervention. For TPAs, EDI files allow you to enjoy an enhanced, more accurate data exchange experience compared to traditional exchange methods with manual entry.
The automation enabled by EDI files streamlines administrative processes, reducing the time and effort required for data entry, document processing, and reconciliation. This leads to improved productivity and faster turnaround times. With EDI files, you can deliver a better experience to your clients and prioritize your time where it matters most.
Shifting to a virtual healthcare data exchange system through EDI files saves more than just time. By eliminating paper-based documentation and manual processing, healthcare organizations can achieve cost savings in terms of paper, printing, postage, and manual labor.
Improved Data Integrity
EDI files maintain data integrity by ensuring the secure and consistent exchange of information. This reduces the risk of data loss, tampering, or misinterpretation. Though some parties may feel weary of shifting to electronic data exchange methods, EDI files in particular are designed to mitigate security risks and data loss.
The Future of EDI Files
EDI 834, 835, and 837 files are integral components of healthcare data exchange, playing essential roles in benefit enrollment, payment processing, and claims submission. These standardized electronic file formats streamline operations, enhance accuracy, and improve efficiency across the healthcare ecosystem.
By leveraging EDI, healthcare organizations can reduce administrative burdens, minimize errors, and optimize their workflows, ultimately leading to improved patient care and financial outcomes. TPAs can enjoy a streamlined, more accurate data exchange that saves time, money, and energy.
EDI files are a strong asset for TPAs seeking a smoother data exchange process, and pairing it with other data-driven solutions can further optimize your workflow.
What if you don’t have access to an EDI 834, 835 or 837 file and need it?
We created a solution to meet this challenge–our Claims & Enrollment Integrations solutions. TPA Stream has experience and expertise in consuming and producing a wide variety of vendor formats. We work with data from vendors like Employee Navigator, Alegeus, WEX Health, and many more. The integration manager does much more than import and export data between software systems. Our solution is designed to keep your process running smoothly with error reporting, file status updates, and more.