Electronic Data Interchange (EDI)

Electronic Data Interchange (EDI) is the automated transfer of data in a specific format following specific data content rules between a health care professional and Medicare, or between Medicare and another health care plan. That transfer may take place with the help of a clearinghouse or billing service that represents a health care professional or another payer. EDI transfers information via computer either to or from Medicare. EDI organizes information according to a specific format set by both the sender and receiver, allowing a computer transaction that doesn’t need human intervention or rekeying on either end. All information contained in an EDI transaction set is, for the most part, the same as on a conventionally printed document.

Use of EDI transactions allows you to submit transactions faster and get payment for claims faster, and to do this at a lower cost than is generally the case for paper or manual transactions. As mentioned in Lesson 1, you must submit initial claims for payment under Medicare electronically unless you qualify for a waiver or exception from this requirement. You’ll learn about waivers in Lesson 3 of this course.

The EDI Helpline is a regional number Medicare customers can call to access information and material about electronic data interchange.