How to Read an EDI 837 File - Tech Tinder (2024)

837 File Format Guide

Modern technological advancements enable the instantaneous sharing of data worldwide. Protecting patient privacy is crucial in offices that provide health services. Healthcare professionals and suppliers communicate healthcare claims using the HIPAA-compliant 837 or EDI file.

Understanding what an EDI file is is crucial before digging further into the 837 form. The electronic data interchange is known as EDI. All firms, including those in the healthcare sector, communicate information to other businesses electronically rather than on paper utilising a standardised electronic method.

This method is used to convey several business forms. One of the most popular forms sent through EDI in the healthcare industry is the HIPAA form 837.

EDI in Relation to Healthcare

It goes without saying that the healthcare sector handles enormous volumes of paperwork in the form of medical records, insurance payments, and more. These firms were badly handicapped by paper forms because of the time they wasted.

The standardisation of forms and documents communicated electronically was further required by the Health Insurance Portability and Accountability Act (HIPAA).

Mail exchanges are not used for EDI healthcare transactions. Every aspect of transmission is electronic. Point-to-point EDI, web-based EDI, EDI through AS/2, EDI VAN, and mobile EDI are all different types of transaction mechanisms.

HIPAA

The law was passed in 1996 to solve a single problem: insurance coverage for those who are between employment. Employees who did not have it lost their insurance protection while they were seeking for work or waited to start a new employment.

HIPAA was also established to ensure patient medical information was safe and limited to authorised personnel only, as well as to stop fraud in the healthcare system.

Another advantage was that HIPAA facilitated the industry's switch from paper healthcare records to electronic ones. The administrative operations of the healthcare system were simplified as a consequence, increasing effectiveness.

To maintain consistency and uniformity when transferring health information between different providers and insurance companies, all entities covered by HIPAA must adhere to the same rules and standards.

Because it ensures that all healthcare organisations participating in the healing process put in place procedures to secure sensitive patient information, patients stand to gain the most from this regulation. Without HIPAA, the healthcare sector would not be compelled to protect this information since there would be no consequences. No one in the business wants to divulge personal information or have it stolen from their computer systems.

After HIPAA, the medical sector adopted stringent security measures, and patients now have the option to decide with whom their information is shared or disseminated. They are able to participate actively in their healthcare because to this.

The 837 File

Formats for the 837

Providers of patient treatment send these documents to payers like HMOs, or health maintenance organisations, PPOs, or government organisations like Medicaid and Medicare. Either through clearinghouses or directly to the agency, they are delivered. The 835 file is used to provide information about coordinated benefits and payments to providers.

The format and information contents of the 837 are established for usage inside the EDI environment by the EDI 837 standard transaction set. This transaction set is used to send encounter data, billing data for medical claims, or both from providers to payers.

Loops, Elements, and Segments

Loops

Each loop in an EDI file is a section or block that comprises many segments with elements and sub-elements. Although loops make up the majority of the EDI, they are sometimes the most challenging to recognise. They often start with an NM or HL section.

Segments

Elements

The claim information in data elements matches what appears on paper forms. Each section has numerous asterisks (*), as can be seen. These are element separators, or asterisks. Additionally, certain sub-elements are separated by colons (:). If there are several colons and asterisks next to each other, the sub-element or element is empty. Some frequent Element Identifier Codes are listed below:

Elements utilise two-digit numerals, whereas sub-elements use one-digit numbers. Sub-elements and elements are associated with a Segment Identifier Code when they are referenced. As an illustration, consider the loop 2300, HI02-1, where HI is the segment identifier code, 02 is the element, and 1 is the sub-element.