You will be able to gain knowledge about Health Care fundamentals while the seasoned professional will gain best practices knowledge. The course deciphers all 9 Health Care EDI transactions; every single segment and element of each of the 9 health care EDI transactions will be analyzed and explained. For the most popular transactions there will be a mapping exercise conducted.

HIPAA EDI Fundamentals and Best Practices

  • Introduction to EDI
  • Health Care EDI Defined
  • Benefits of Health Care EDI
  • X12 Standards
  • X12N Workgroups
  • WEDI – Workgroup for Electronic Data Interchange
  • Software & Infrastructure for EDI (What’s a Translator &Mapper)
  • EDI Connectivity (e.g. SFTP, HTTPS, Web Services)

EDI Enveloping & TR3 Viewing

  • EDI Enveloping ISA-GS-ST-SE
  • Key terms related to the structure of EDI (e.g. qualifier, segment, terminator, delimiter)
  • Instructions on using the TR3 manual to look at transactions, segments and data elements,
  • situational rules and loops.
  • LOOP IDs – Deep Dive (HL, NM1,CLM,etc)
  • Instructions on viewing EDI Implementation Guides and Mapping Specs
  • Health Industry Related Code Sets – Clinical and Non-Clinical

Deciphering HIPAA EDI Transactions – Enrollment& Eligibility

  • Deciphering 834 Benefit Enrollment 005010X220A1
  • 834 Update File
  • 834 Audit File
  • 834 Exchange Enrollment 005010X307
  • 820 Premium Payment 005010X218
  • Deciphering 270-271 Eligibility Enquiry and Response & 271 005010X279A1
  • 270 Eligibility Inquiry
  • 271 Response To Eligibility Inquiry
  • 278 Prior Authorizations and Referral Authorizations
  • CAQH Requirements – Real Time & Batch

Deciphering EDI Transactions – 837 Claims & Acknowledgements

  • 837 Professional Claim 005010X222A1
  • 837 Institutional Claim 005010X223A2
  • 837 Dental Claim 005010X223A2
  • TA1 Acknowledgment
  • 999 Acknowledgement 005010X231
  • 277CA Claim Acknowledgment 005010X214
  • Medicare MAO Acknowledgments
  • 276-277 Claim Status Inquiry & Response 005010X212

Deciphering EDI Transactions – 835 Health Care Claim Payment/Advice

HIPAA X12 835 Health Care Claim Payment/Advice

  • Deciphering 835 005010X221A1
  • Claim Adjustment Group Codes
  • Claim Adjustment Reason Codes
  • Line Level Balancing
  • Claim Level Balancing
  • Transaction Level Balancing
  • Provider Level Adjustments
  • 835 Best Practices

Detailed Course Content – Advanced HIPAA EDI Training All Industries

Enrollment, Eligibility and Prior/Referral Authorizations:

834 Benefit Enrollment Advanced EDI Mapping Exercises and Implementation Concepts. 

We will include a discussion of Benefit Enrollment implementations with commercial sponsors and health care exchanges. We will cover the CMS Companion guide and other state exchange companion guides. We’ll also explain how the 820 005010X306 Health Insurance Exchange is used alongside the 834.


270/271 Eligibility Inquiry and Response – Advanced EDI Mapping Exercises and Implementation Concepts:
We’ll cover advanced Grace-Period and Paid-Through-Date details. Instructor will cover a lot of interesting things that are happening to this transaction at the ANSI X12N Workgroup for the 270/271. We’ll discuss advanced concepts such as tiered benefits and tiered networks. The instructor will also cover CAQH Core operating rules and show you how this transaction be exchanged in real time.

278 Prior Authorization and Referral Authorization – Advanced EDI Mapping Exercises:
All payers, plan sponsors, providers, utilization management and other entities involved in health care services review benefit from this training session. In addition to conducting an EDI mapping exercise, we will have more time to discuss best practices of implementation. This transaction is also getting a lot of CAQH Core operating rules attention and buzz and changes are happening to the 278 at the X12 conference. A case study will be provided on how a 278 was used to help with clinical decision support and prior authorizations.