EDI 278

How the EDI 278 Transaction Works

1. A healthcare provider submits an EDI 278 request to an insurance company or payor to seek approval for a medical service.
2. The insurance payor processes the request and evaluates whether the service is covered under the patient’s insurance plan.
3. The payor sends an EDI 278 response, indicating whether the request is approved, denied, or requires additional information.
4. If approved, the provider proceeds with the service; if denied, the provider may appeal the decision or adjust the treatment plan accordingly.

What Information Does the EDI 278 Include?

The EDI 278 transaction includes the following key information:

• Patient Information – Name, date of birth, member ID, and insurance details.
• Provider Information – Provider name, National Provider Identifier (NPI), and contact details.
• Service Request – Details of the requested service, including procedure codes (CPT/HCPCS), diagnosis codes (ICD-10), and requested service dates.
• Request Type – Whether it’s for prior authorization, referral, or hospital admission certification.
• Insurance Information – Name and ID of the insurance company.
• Decision – The response from the insurance company, indicating if the request is approved, denied, or needs more information.
• Additional Information – Any extra clinical data or details required for approval.
  Time Frames – Time limits for making decisions on the request.
   

HIPAA Compliance and EDI 278

As of March 31, 2012, healthcare providers must comply with HIPAA version 5010 for EDI transactions. EDI/HQ™ Healthcare software ensures full HIPAA-compliant EDI processing, offering:

• Advanced EDI translation
• Superior mapping and integration
• Enhanced data management