How EDI 835 and 837 Are Different?

EDI 835 and 837 are two transaction types usually concerned with insurance matters. Especially in the case of claim and its application. Now, to differentiate between them we need to consider a case in which a claimant, one healthcare provider, and the insurance providing company exist altogether.

Before proceeding ahead, we need to be clear about the healthcare provider and insurance provider both, as the one which provides the healthcare facility is not necessarily the insurance provider always. 

In fact, a healthcare provider is mostly the employer which offers the healthcare service to its employee i.e. ‘the claimant’ in our case here. However, the insurance company is the one which pays when the claim is applied.

Also read the benefits of deploying a medical software and how it can help in managing claims and overall benefits administration.

Now when we are clear about the basics, let us consider the case we have assumed the characters from, the storyline would be sufficient to differentiate EDI 835 from EDI 837. Assume, there is an employee who works in an enterprise software development company based in California, USA. 

The company i.e. healthcare provider has to offer the health insurance to its employee under the healthcare act of the federal government. According to which, the employee would choose a specific health safety plan and enroll as an employee for specific benefit.

This entire process of enrolling an employee is done via EDI 834, and the overall work related to benefits is called employee benefits administration and is accomplished via different types EDI including-

• WEB EDI
• MOBILE EDI
• CLOUD BASED EDI
• EDI VAN
• EDI Managed Services, etc.
• EDI Outsourcing Services

Considering the case that the employee later requires to claim for its same health insurance. Here, the employer would send the request to the insurance providing organization for the specific amount that has been requested by the hospital or medical body. This information is to be sent via EDI 837.

Now, considering the case from the insurance providing company.

Supposing that the insurance company has received the claim request and the details about the different benefits and amount that has been claimed by the claimant.

The information would be in the form of EDI 835 transaction order and now the insurance company would scrutinize the details in it. This process generally takes a week or two.

But when the insurance company replies back or sends the aforesaid amount, whichever it finds worth sending and verifies, it sends through EDI 835.

Means, we can say that, if EDI 837 is a request order, EDI 835 is a reply to it.

• EDI 835

It is also termed as ERA or Electronic Remittance Advice. However, both EDI 835 & 837 are two transaction types but EDI 835 is an information based transaction that consists of information regarding the claim or the payment concerned with it.

• EDI 837

EDI 837, on the other hand, is the request order consisting of all the information regarding the claims that are requested by the customer or the beneficiary. However, the payment is subject to verification.

However, both EDI 835 and EDI 837 have a lot to dig upon deeply, but the basic difference that we should know is quite this much. 

Out of 400 different standards for the transaction types, EDI 8434, 835, 837 are some of the most utilized standard formats across the globe. Make sure you know EDI before deploying it into your healthcare business because things change when you keep generalized and strictly standardized stuff like EDI into a business. 

You would start getting the filtered audience which is as credible as you are after implementing EDI and its standards set by ANSI and that’s the best part as it mitigates the biggest risk of fraud influentially.