Simplifying Healthcare Data and Claims Management: Introducing Databricks X12 EDI Ember

EDI and its role in the Healthcare Ecosystem

Electronic Data Interchange (EDI) is a semi-structured data exchange method allowing healthcare organizations like Payers, Providers, etc., to seamlessly share vital transactional information electronically. Its standardized approach ensures accuracy and consistency across healthcare operations. EDI transactions used for various healthcare operations include:

• Claims submissions, Remittance, and Benefit enrollment (837, 835, 834)
• Eligibility verifications (270, 271)
• Electronic funds transfers (EFTs)

With the global healthcare EDI market expected to surpass $7 billion by 2029, driven by increasing claims submissions, the adoption of APIs, and regulatory mandates, efficient EDI workflows are more essential than ever for scaling claims submissions, meeting regulatory demands, and powering real-time healthcare collaboration. Healthcare organizations leverage EDI to conduct core operational financial functions for services and payments. Additionally, claims, remittance, and enrollment information power many downstream analytical programs such as payment integrity workstreams, Value Based Care (VBC), and narrow network arrangements, and quality measures like Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Star ratings. Importantly, as more providers engage in VBCs, they have a greater need to seamlessly ingest and analyze EDIs.

Despite ongoing technological advancements, key challenges remain in how healthcare organizations interact with EDI data. First, the exchange and adjudication process-from claims submission to payment-remains lengthy and fragmented. Second, semi-structured EDI information is often difficult to access due to its format, complexity, and limited tooling to transform it into analytics-ready data. Lastly, much of the EDI data is consumed only downstream of proprietary adjudication systems, which offer limited transparency and restrict organizations from gaining timely, actionable insights into financial and clinical performance.