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 - ANSI is the HIPAA standard format for electronic claims.
ASCA - Administrative Simplification Compliance Act - ASCA is a law that grants an extension to comply with HIPAA transactions and code sets requirements. This extension only applies to large covered entities that submitted a compliance plan by October 15, 2002.
ASC X12 - Accredited Standards Committee - The ASC was chartered by the ANSI to develop and maintain uniform standards to facilitate electronic data interchange.
BBS - Bulletin Board System - The BBS is a system that Trading Partners use to send and receive electronic transactions and reports.
BDCL - Batch Detail Control Listing - The BDCL is a report generated by the Multi Carrier System (MCS) during prepass editing. EDISS sends the BDCL report to Trading Partners to inform them of the disposition of their claims sent within a batch. Claims go through prepass edits before being accepted into the MCS claims processing system.
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.
CCR - Claims Confirmation Report - The CCR is a report designed to inform Trading Partners of the status of their ANSI electronic claim files submitted to EDI Support Services (EDISS). This report is created after EDISS translates the incoming file. EDISS then distributes the CCR to the Trading Partners via the BBS.
CLAREDI - CLAREDI provides comprehensive HIPAA EDI standard transaction testing and certification solutions to help healthcare providers, payers, and clearinghouses produce HIPAA compliant transactions.
Clearinghouse - A clearinghouse is 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.
Covered Entity - A covered 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.
Covered Transaction - Covered transactions are those transactions that must be compliant with HIPAA.
Delimiter - A delimiter is character used in the ASC X12 standard to separate two data elements (or sub elements) or to terminate a segment.
DSMO - Designated Standard Maintenance Organizations - DSMOs are responsible to maintain standards for health care transactions adopted by the Secretary, and receive and process requests for adopting a new standard or modifying an adopted standard.
EDI - Electronic Data Interchange - EDI describes the electronic exchange of business documents using standard formats.
EDISS - Electronic Data Interchange Support Services - EDISS is the department responsible for the collection, translation and routing of electronic health care claims. EDISS also maintains and supports PC-ACE Pro32, EDISS' free/low cost billing software.
EDS - EDS is the Medicare Part B data center responsible for maintaining the MCS claims processing system for the states of Colorado, Iowa, North Dakota, South Dakota, and Wyoming.
Element - An element is 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.
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.
Forms Central - Location of all forms on the EDISS website (www.edissweb.com) necessary to register with EDISS for several transactions.
Functional Acknowledgement - The Functional Acknowledgement, also known as a 997 or ACK report, is a report used to indicate the results of the syntactical analysis of an electronic transaction.
Health Insurance Reform - Provisions of HIPAA that protect health insurance coverage for workers and their families when they change or lose their jobs.
HIPAA - Health Insurance Portability and Accountability Act that defines provisions on health insurance reform, administrative simplification, privacy and security.
HyperTerminal - HyperTerminal is a program included with the Microsoft Windows operating system. HyperTerminal can be used to connect to other computers, bulletin board systems and other online services using either a modem or a null modem cable.
IG - Implementation Guide - The IG defines standardized data requirements and content for ANSI transactions. Each ANSI transaction has its own IG.
Interchange Acknowledgement - The Interchange Acknowledgement, also known as TA1 report, identifies the status of a processed ANSI interchange header and trailer.
IVANS - IVANS is a network service provider supplying connectivity to Electronic Trading Partners. Instead of connecting directly into the EDISS modem bank, users connect to one of the IVANS' local dial access numbers , which will route data accordingly.
Loops - Loops are groups of semantically related segments in an ANSI file.
M2 - EDISS uses the M2 Translator to authentic, validate, translate and route electronic transactions to and from multiple claim payment systems EDISS maintains. The system is fully HIPAA compliant and is able to handle all required HIPAA transactions.
MCS - Multi Carrier System - The MCS processes Medicare Part B claims.
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 Pro32 - PC-ACE Pro32 is EDISS free/low-cost billing software. Providers can use PC-ACE Pro32 to 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.
PPTN - Professional Provider Telecommunications Network - PPTN is an online resource for Medicare Part B providers to access beneficiary eligibility information, current claim status, pricing information, provider summary data, etc.
Qualifier - A qualifier is a code that identifies what information will be submitted in the following element.
Registration Form - The registration form is completed by provider and submitted to EDISS in order to set up a provider facility for electronic claim submission.
Security - The HIPAA Security regulation mandates how protected health information is stored and accessed.
Segment - A segment is 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.
SNIP - Strategic National Implementation Process - The SNIP is a group constituted under the Workgroup for Electronic Data Interchange (WEDI) to guide the healthcare industry in an orderly implementation of HIPAA-compliant EDI.
Software Vendor - A software vendor is an entity that supplies a medical billing software product that can be used to create electronic claim files.
Submitter ID - Each provider who is enrolled with EDI is assigned a unique Submitter ID.
TA1 - The TA1, also known as Interchange Acknowledgement, reports the processing status of a received interchange header and trailer.
Testing - EDISS uses testing to evaluate submitted electronic file data for accuracy against a specification. The specification used by EDISS is the Implementation Guide.
Trading Partner - A Trading Partner is an entity which sends and/or receives electronic health care transactions to/from EDISS. A Trading Partner could be a 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. A Trading Partner ID could be issued to a provider, billing group, billing service, clearinghouse or payer.
Translation - Translation is 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:
837P - Professional Health Care Claim Transaction
837I - Institutional Health Care Claim Transaction
837D - Dental Health Care Claim Transaction
835 - Health Care Claim Payment/Advice Transaction
276/277 - Health Care Claim Status Request and Response Transaction
270/271 - Health Care Eligibility Benefit Request and Response Transaction
Transaction Acknowledgement - (also known as TRN) - Report that sums up the basic attributes of a submitted electronic transaction.
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 - 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 - A vendor is 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.
Verizon - Verizon is the Medicare Part B data center responsible for maintaining the MCS claims processing system for the states of Alaska, Arizona, Hawaii, Nevada, Oregon, and Washington.
Ability - Ability is a network service provider supplying connectivity to Electronic Trading Partners via the Internet. Ability does not use dial-up, leased-line, or frame-relay technologies.
WEDI - Workgroup for Electronic Data Interchange - The WEDI is a group dedicated to fostering widespread support for the adoption of electronic commerce in healthcare.