EDI 275 Patient Information Transaction Set

What is an EDI 275 Patient Information Transaction Set?

The EDI 275 Patient Information Transaction Set is a standardized format used in electronic data interchange (EDI) to exchange patient information between healthcare entities. It’s used to send detailed patient information, such as medical records, billing data, and other healthcare documents.

EDI 275 is primarily used by healthcare providers, insurance companies, and other entities involved in patient care and administration. It ensures patient information is shared quickly, accurately, and securely, reducing paperwork and errors.

Workflow for the Exchange of EDI 275 Patient Information

The workflow for exchanging EDI 275 Patient Information involves several vital steps to ensure secure, accurate, and efficient data transfer between healthcare entities.

• This process begins with the sending organization, such as a healthcare provider or hospital, creating the EDI 275 file. The sender collects the necessary patient information, including demographic details, medical history, and other relevant data, and formats this data according to the X12 EDI 275 standard. This ensures the information is structured consistently for electronic transmission.
• Once the EDI 275 file is prepared, it undergoes validation to check for errors and compliance with the required format. This validation step is crucial to prevent any issues during transmission or processing by the receiving entity. After validation, the file is transmitted over a secure network, typically using protocols like AS2 (Applicability Statement 2) or SFTP (Secure File Transfer Protocol). These protocols provide encryption and authentication to protect sensitive patient information during transfer, ensuring compliance with regulations like HIPAA (Health Insurance Portability and Accountability Act).
• Upon receiving the EDI 275 file, the receiving entity, such as an insurance company or another healthcare provider, processes the file by performing its validation checks to ensure data integrity and format compliance. Once validated, the information is integrated into the recipient’s internal systems, such as electronic health records (EHR) or claims processing systems. This integration allows the recipient to access and utilize the patient information for various purposes, such as claims adjudication, medical reviews, or care coordination.

Throughout this workflow, it’s important to ensure that robust error-handling mechanisms are in place to address any issues that may arise during the transmission or processing of the EDI 275 file. This includes generating acknowledgment messages, such as the EDI 997 Functional Acknowledgment, which informs the sender that the file was received and whether it passed validation checks.

If errors are detected, the sender and receiver can coordinate to resolve them, ensuring the accurate and timely exchange of patient information.  

EDI X12 275 File Format Sample

The EDI 275 follows the X12 standard, specifically tailored for healthcare data. ISA*00**00**ZZ*SENDER*ZZ*RECEIVER*240805*0748*^*00601*000000001*0*T*>~

GS*PI*SENDERGS*RECEIVERGS*20240805*074839*000000001*X*006010~

ST*275*0001*006010~

BGN*02*112220221*20180514~

NM1*PR*2*JOHN*****XV*1234~

NM1*41*1*SMITH*LAWRANCE*T***46*1112223334~

NM1*1P*2*JOHN*RONALD*M**M.D.*XX*123456789~

DMG*D8*19800101*M~

NX1*1P~

N3*PO BOX 123*157 WEST 57TH STREET~

N4*ASTERA*OH*43017~

NM1*QC*1*SMITH*LAWRANCE*T**PH.D*MI*4599083123141~

PER*IC*DR. SMITH*TE*555-123-4567~

REF*X1*2033990204933~

LX*1~

TRN*1*STFA423451~

DTP*358*D8*20240313~

CAT*AD*HL~

OOI*1*47*ATTACHMENT~

BDS*B64*16*THIS IS CLINICAL DOCUMENT PLACE HOLDER IN BINARY FORM~

SE*20*0001~

GE*1*000000001~

IEA*1*000000001~

Here’s a simplified example and an explanation of each segment:

• The ISA (Interchange Control Header) segment contains sender and receiver information, date, time, and control numbers.
• The GS (Functional Group Header) segment groups related transaction sets and contains control information.
• The ST (Transaction Set Header) segment indicates the start of a transaction set and assigns a control number.
• The BGN (Beginning Segment for Document) segment provides document identification and purpose.
• The NM1 (Individual or Organizational Name) segment provides patient and provider names and identifiers.
• The DMG (Demographic Information) segment provides the date of birth and gender.
• The NX1 (Property or Entity Information) segment provides the attributes of a property or an entity.
• The N3 (Patient Address) segment contains the address information for the patient.
• The N4 (Patient City, State, ZIP Code) segment contains the patient’s city, state, and ZIP code.
• The NM1 (Provider Information) segment provides the provider’s name and identifier.
• The PER (Administrative Communications Contact) segment provides contact information.
• The REF (Reference Identification) segment contains reference identifiers such as insurance policy numbers.
• The LX (Assigned Number) segment provides a control number for looping structures.
• The TRN (TRACE) Segment provides unique identification of a transaction to an application.
• The DTP (Date or Time or Period) segment specifies a date, a time, or a certain time.
• The CAT (Category of Patient Information Service) specifies categories of patient information service.
• The OOI (Associated Objects) segment specifies a document or attachment related to the transaction.
• The BDS (Binary Data Structure) segment allows binary data to be transferred through it.
• The SE (Transaction Set Trailer) segment refers to the end of the transaction set and provides a segment count.
• The GE (Functional Group Trailer) segment pertains to the end of the functional group and provides a control number.
• The IEA (Interchange Control Trailer) segment marks the end of the interchange and provides a control number.

This is a basic example. Real-world EDI 275 files can be much more complex, depending on the specifics of the patient information and the requirements of the entities exchanging data.

Benefits of EDI 275

1. Standardization and Consistency: EDI 275 ensures patient information is exchanged in a standardized format. This consistency reduces the likelihood of errors associated with manual data entry and interpretation, enhancing data accuracy and reliability.
2. Improved Data Security: EDI 275 utilizes secure transmission protocols like AS2 or SFTP to protect sensitive patient information during transfer. Compliance with HIPAA regulations ensures data privacy and security, minimizing the risk of data breaches.
3. Enhanced Efficiency: Automating the exchange of patient information through EDI 275 streamlines administrative processes, reducing the time and effort required for manual data handling. It allows healthcare providers and payers to focus on more critical tasks like patient care and claims processing.
4. Reduced Operational Costs: The automation and standardization provided by EDI 275 reduce the need for paper-based processes and manual intervention. This leads to significant cost savings in printing, mailing, and data entry labor.
5. Faster Processing Times: EDI 275 enables the swift transmission and processing of patient information, facilitating quicker decision-making and response times. These include claim adjudication, medical reviews, and care coordination, improving operational efficiency.
6. Enhanced Collaboration: EDI 275 promotes better communication and data sharing between healthcare entities, providers, payers, and clearinghouses. This improved collaboration leads to more coordinated, effective patient care and streamlined administrative workflows.
7. Error Reduction: Automated validation checks and standardized data formats minimize the occurrence of data entry errors. This leads to more accurate and reliable patient information, reducing the need for corrections and rework.

Conclusion

Efficient healthcare data exchange is crucial for smooth operations and compliance with industry standards. The EDI 275 transaction is essential for sharing detailed patient information, like medical records and billing data, between providers and payers.

Managing EDI 275 transactions requires tools to parse, validate, map, and automate data. Astera EDIConnect is a powerful EDI solution that makes it easy to send and receive EDI 275 files. It has a built-in parser, validator, and transaction builder and supports ASC X12 and EDIFACT formats. Additionally, it offers code-free data mapping to EDI formats and workflow automation to streamline the EDI process.

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