EDI file formatting standards for medical recordkeeping

An EDI file will start out with ISA* and end with something like...

GE*1*129768013~
IEA*1*129768013~

 
 

Between this header and footer there will be individual records, sometimes one per file or sometimes with numerous records per file. All records starts out with ST* followed by an integer and end with SE* followed by an integer and eventually the next tilde. The number after ST* denotes the type of record. ST*834 is for members for example while ST*837 is for claims. The number after the SE* denotes a total number of rows of data between the ST* and the SE* for the record which is sort of like a record set honestly. Members and claims are pretty much industry standard terms in the healthcare insurance space. Members (which make doctor visits while holding insurance) have claims which get graded in an adjudication process. Clients have members insofar that employers (businesses) have employees. The clients are the employers and the members the employees. Providers are doctors' offices. Different insurance plans are referred to as groups and a group will encircle n number of members and denote what providers they may use, i.e. answering the question: Is a provider in group? The domain, as Eric Evans might whiteboard it out, is already halfway congealed.