The X12 Protocol: The Required EDI Protocol For HIPAA Compliance

HIPAA Compliance EDIThe EDI Protocol That Protects Patient Records

EDI protocols are the languages used by EDI software to transfer data securely from one computer to another. Each protocol reflects a set of universal guidelines that dictate how the data is encrypted and configured while in transit.

Different protocols exist to serve different industries, types of data, and different types of software on the sending/receiving ends. Due to the sensitive nature of the data collected in the healthcare industry, the EDI protocols used must adhere to strict guidelines set by HIPAA.

HIPAA and EDIHIPAA and EDI

The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to create a variety of regulations in the healthcare industry – many of which are related to insurance eligibility and protection for Americans when switching insurance carriers after changing jobs.

However, HIPAA is mostly known for the regulations of patient privacy and the protection of healthcare data. As a result of HIPAA, a national standard for EDI transactions exists to allow all healthcare facilities to transfer patient records and other valuable data securely and seamlessly, regardless of what in-house software they’re using to maintain their records.

Therefore, a hospital in Chicago can transfer patient records to a hospital in Seattle instantly and electronically without the risk of that information getting intercepted, as could happen through email. The data is converted into its EDI format and transferred through an EDI VAN, which encrypts the data while in transit.

The EDI protocol required by HIPAA for the healthcare industry is the X12 protocol.

The X12 Protocol

The X12 protocol has been in use long before the enactment of HIPAA in the mid-90’s – originally developed in 1979 by The National Standards Institute (ANSI) as a secure form of EDI communication.
Most commonly used by the military and logistics industries at first, the X12 protocol remains one of the most popular EDI protocols today. Despite the invention of new technologies, the X12 protocol is still trusted by governments and financial institutions around the world for its strong security.

Important HIPAA EDI Transaction Sets

Using the X12 protocol, different transactions sets exist for each type of document transmitted through an EDI VAN. For example, an insurance claim and a benefit inquiry both require their own X12 transaction set.

X12 transaction sets have three main components:

  1. Data – The individual data elements, such as a name or dollar amount.
  2. Segments – The categories for each type of data.
  3. Loops – Groups of segments organized together.

If you’re a BOLD VAN customer, you don’t have to worry about structuring EDI transaction sets because our software handles everything for you.

Common HIPAA EDI X12 Transaction Sets

  • 270 Health Care Eligibility/Benefit Inquiry – Requests eligibility/benefits information about a patient.
  • 271 Health Care Eligibility/Benefit Response – Sends requested eligibility/benefits information about a patient.
  • 276 Health Care Claim Status Request – Inquires about the status of a health care claim.
  • 277 Health Care Claim Status Notification – Either provides a health care claim status update or can also be used to request additional information.
  • 278 Health Care Service Review Information – Sends patient or insurance subscriber information for review or certification.
  • 820 Payroll Deducted (or Premium Payment for Insurance) – Either used to make a premium payment or to authorize a bank to submit payment.
  • 834 Benefit Enrollment and Maintenance – Used to enroll members to a healthcare organization or insurance company by an employer or association.
  • 835 Health Care Claim Payment/Advice – Used to authorize a payment or send Explanation of Benefits remittance advice.
  • 837 Health Care Claim – Sends health care claim billing information from providers to payers.

Healthcare organizations need an EDI VAN to securely exchange data with insurance companies and other providers. However, EDI VANs vary greatly in quality and cost.

In fact, most EDI providers charge by the kilo-character, resulting in huge monthly EDI bills as a result of the high volume of EDI data exchanged by healthcare providers. At BOLD VAN, we take a revolutionary approach by charging a fixed rate based on the number of active trading partners in your EDI network – not the data you send.

That means you get unlimited EDI data each month for one low, predictable rate. Plus, you enjoy our fast, secure, and reliable (99.998% uptime) EDI VAN, supported by a team of EDI experts with nearly 30 years of experience.

Learn more about BOLD VAN’s Trading Partner Pricing.

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