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Electronic Data Interchange (EDI) Terminology

There is a lot of unique vocabulary in the world of electronic claim submission. Listed below are the definitions of several terms and acronyms you may often see and hear:

Administrative Simplification – Regulations within the Health Insurance Portability and Accountability Act (HIPAA) that are designed to reduce the administrative burden associated with providing health care and to increase the efficiency and cost effectiveness of the US health care system. These regulations mandate the implementation of a set of standards to be used by all sectors of the health care industry.

ANSI (American National Standards Institute) – The HIPAA standard format for electronic claims.

ASCA (Administrative Simplification Compliance Act) – CMS regulations dictate that Medicare providers who submit the largest percentage of paper claims, be sent notification and can request approval to continue to submit paper claims if they meet certain criteria.

ASC X12 (Accredited Standards Committee) – The ASC was chartered by the ANSI to develop and maintain uniform standards to facilitate electronic data interchange.

Billing Group – A billing group is established for providers who are not linked in any way but have the same billing contact that uses the same software to send claims for those providers. EDISS determines billing groups.

Billing Service – A billing service is an entity that assists a provider bill for services performed.

Blanket Approval – Blanket Approval status indicates a Billing Service or Clearinghouse is no longer required to test each individual provider within a particular Line of Business when the Billing Service or Clearinghouse has the required number of providers in production for that state.

Clearinghouse – An entity that receives provider claim data, translates the data to the ANSI format and then forwards the data to EDISS on behalf of the provider.

CMS (Centers for Medicare & Medicaid Services) – The CMS is a federal agency within the United States Department of Health and Human Services that regulates Medicare, Medicaid and other health care programs.

Code Set – A code set is a set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes or medical procedure codes.

Delimiter – A delimiter is character used in the ASC X12 standard to separate two data elements (or sub elements) or to terminate a segment.

Direct Data Entry (DDE) – An interface that allows providers to verify eligibility and check claim status (paid, denied or pending). Providers can check the status of claims within three days of a successful transmission. DDE requires a connectivity service provided by an external company to establish the connection.

EDISS Gateway System – The EDISS Gateway System is a system that Trading Partners use to send and receive electronic transactions and reports.

EDISS (Electronic Data Interchange Support Services) – The department responsible for the collection, translation and routing of electronic health care claims. EDISS also maintains and supports the PC-ACE software.

EDISS Connect – This is the registration and testing website for Trading Partners for EDISS. Only Commercial LOBs can currently test in Connect at this time.

Element – The smallest named unit of information in the ASC X12 standard. Elements are defined as either simple or component, and are assigned a unique reference number. Each element has a name, description, type, minimum and maximum length.

Entity – An entity is a health plan, health care clearinghouse or health care provider who transmits health information in electronic form in connection with a HIPAA transaction.

ERA (Electronic Remittance Advice) – The ERA lists health care claims billed and the payment status of those claims. The report is created by the payer and delivered to the provider.

Functional Acknowledgement – The Functional Acknowledgement, also known as a 999 or ACK report, is a report used to indicate the results of the syntactical analysis of an electronic transaction.

HIPAA (Health Insurance Portability and Accountability Act) – HIPAA defines provisions on health insurance reform, administrative simplification, privacy and security.

Interchange Acknowledgement – The Interchange Acknowledgement, also known as TA1 report, identifies the status of a processed ANSI interchange header and trailer.

Loops – Loops are groups of semantically related segments in an ANSI file.

MCS (Multi Carrier System) – The MCS processes Medicare Part B claims and houses patient and provider information and credentials.

Noridian Medicare Portal (NMP) – The NMP is a secure provider internet website that allows providers to check claim status, eligibility, financial information, appeals and remittance advices.

NPI (National Provider Identifier) – The NPI is a unique identification number for an individual or entity that provides health care services and supplies.

PC-ACE – PC-ACE is EDISS' free/low-cost billing software supported by EDI. Using this, providers can create HIPAA-compliant electronic health care claims, view and print ERAs and create health care claim status inquiries.

PHI (Protected Health Information) – PHI is individually identifiable health information about a person, which covered entities may not disclose without specific consent or authorization from the person. The information that is protected consists of the following: name, specific dates (birth, admission, discharge, and death), telephone number, Social Security number, medical record number, photographs and geographic region.

PPACA (Patient Protection and Affordable Care Act) – High volume users (providers or vendors) who connect directly to NHS via a dedicated SOAP connection. Users send/receive 270/271 and 276/277 transactions for IAMCD and/or BCBS lines of business.

PPTN (Professional Provider Telecommunications Network) – An online resource for Medicare Part B providers to access beneficiary eligibility information, current claim status, pricing information, provider summary data, etc.

Qualifier – A code that identifies what information will be submitted in the following element(s).

Segment – An intermediate unit of information in a transaction set that consists of a segment identifier, one or more composite data structures or simple data elements each preceded by a data element separator and succeeded by a segment terminator. Each segment has a unique two or three-character identifier, a name and a purpose.

Software Vendor – An entity that supplies a medical billing software product that can be used to create electronic claim files.

Technical Review Guide (TR3) – The TR3 defines standardized data requirements and content for ANSI transactions. Each ANSI transaction has its own implementation guide.

Testing – EDISS uses testing to evaluate submitted electronic file data for accuracy against a specification.

Trading Partner – An entity which sends and/or receives electronic health care transactions to/from EDISS. (i.e.: provider, billing group, billing service, clearinghouse or payer.)

Trading Partner ID – EDISS assigns a Trading Partner ID to the entity that connects with EDISS to send/receive an electronic transaction.

Translation – The process of changing ANSI electronic claims transactions into a format that can be understood by the claims processing systems.

Transaction – Under HIPAA, this is the exchange of information between two parties to carry out financial or administrative activities related to health care. HIPAA transactions include:

270/271 – Health Care Eligibility Benefit Request and Response Transaction
276/277 – Health Care Claim Status Request and Response Transaction
278 – Prior Authorization Request and Review Transaction
837D – Dental Health Care Claim Transaction
837I – Institutional Health Care Claim Transaction
837P – Professional Health Care Claim Transaction
820 – Health Care Claim Premium Payment Transaction
834 – Benefit Enrollment and Maintenance Transaction
835 – Health Care Claim Payment/Advice Transaction

Transaction Acknowledgement – Also known as TRN – A report that sums up the basic attributes of a submitted electronic transaction (for Iowa Medicaid only).

Transaction Set – Smallest meaningful set of information exchanged between Trading Partners composed of a transaction set header control segment, one or more data segments in a specified order and a transaction set trailer control segment.

Transactions and Code Sets – A HIPAA regulation that directs the Secretary of Health and Human Services (HHS) to mandate the use of national standards for the electronic transfer of certain health care data.

Vendor – An entity that provides hardware, software and/or ongoing technical support for covered entities. In EDI, a vendor can be classified as a software vendor, billing service or clearinghouse.