What is Electronic Data Interchange (EDI)?

Electronic Data Interchange (EDI) is the standardized, secure electronic transmission of business documents—specifically healthcare claims and remittances—between providers, payers, and financial clearinghouses.

In RCM, EDI relies on mandated formats (like the X12 Data standard) to ensure that claims, eligibility inquiries, and payment acknowledgements can be instantly understood and processed by different computer systems, eliminating the need for paper, faxes, or manual data entry.

Why EDI is Critical for CFOs and Financial Leaders

EDI is the foundational technology required for high-velocity RCM and is essential for minimizing administrative overhead.

• Accelerated Cash Flow: EDI allows claims to be submitted and remittances (payments) to be posted virtually instantly, drastically accelerating the time a service takes to become cash and lowering Days in Accounts Receivable (A/R).
• Reduced Cost and Error: Eliminating paper-based claims, mailing, and manual entry directly reduces the Cost to Collect and virtually eliminates clerical errors that lead to rejections.
• Compliance Baseline: EDI compliance is a non-negotiable standard for nearly all major commercial and government payers, ensuring your claim transmissions meet legal and payer requirements.

Key Use Cases: EDI in Automated RCM

EDI is the backbone used by RCM Automation for communication:

• Claims Submission (837): The standard EDI format for submitting professional, institutional, and dental claims directly to the payer.
• Electronic Remittance Advice (835): The EDI format used by payers to return payment details and adjudication results, allowing RCM systems to automatically perform Payment Posting.
• Eligibility Inquiry/Response (270/271): The EDI messages used by RCM systems to quickly and automatically verify patient eligibility before a service is rendered.

EDI vs. Paper Claims

The difference is speed and efficiency:

• EDI: Standardized digital transmission, enabling near-instantaneous processing, high Clean Claim Rate (CCR), and automatic posting.
• Paper Claims: Requires manual printing, mailing, data entry by the payer, leading to delays, high administrative costs, and frequent human error.

Resources and Education

• Candid Health Solution: Platform Overview /solution
• Product Claims: Claims Submission /product/claims