EDI Healthcare Transaction Guide by Sender and Receiver
EDI Healthcare Transactions Decoded:
Who Sends, Who Receives and Why
Understand who sends and receives common X12 EDI healthcare transactions and how each supports eligibility, claims, payments, enrollment and acknowledgments.
How X12 EDI Transactions Support Healthcare Data Exchange
Across the healthcare ecosystem, patient encounters trigger X12 EDI transactions involving insurance benefits, claims and payments. Senders and receivers of EDI transactions include healthcare providers, professionals and institutions; clearinghouses; employers; insurance companies; and government entities such as Medicare. HIPAA (Health Insurance Portability and Accountability Act) requires that healthcare organizations to follow specific X12 EDI standards for submitting and processing insurance claims.
Benefit plans and insurance types communicated through EDI messages include medical, dental, vision, short-term disability, long-term disability and more. EDI transactions can be used to determine eligibility and authorization, coordinate benefits, track claims and payment status, and obtain payer specifics.
X12 EDI data integration is critical in healthcare today and helps ensure interoperability among all upstream and downstream participants.
CHART: X12 EDI Healthcare Information Exchange Transactions and Participants
PilotFish created this user-friendly chart as a “cheat sheet” or guide to list the core transactions vital to healthcare EDI data exchange and integration.
You’ll find the typical sender, receiver and the purpose of the transaction and workflow.
We have outlined the EDI transactions used in Healthcare Eligibility & Benefits, Claims Management, Payments & Remittances, and Enrollment & Maintenance. The Acknowledgement messages used to confirm transaction receipt and/or information are also listed.
| EDI Transaction | Sender | Receiver | Description |
|---|---|---|---|
| EDI 270 | Healthcare provider or billing service | Health insurance payer | Inquires about a patient's eligibility and benefits with a health insurance payer. |
| EDI 271 | Health insurance payer | Healthcare provider or billing service | Response to the eligibility inquiry (EDI 270) and it provides detailed information on a patient's eligibility and benefits from the health insurance payer. |
| EDI 275 | Healthcare provider or billing service | Health insurance payer | Communicates patient demographic and administrative information, such as updates or corrections to patient records, from the provider to the health insurance payer. |
| EDI 276 | Healthcare provider or billing service | Health insurance payer | Requests the status of a submitted claim from the health insurance payer. |
| EDI 277 | Health insurance payer | Healthcare provider or billing service | Response to the claim status request (EDI 276) and provides detailed information about the status of a submitted claim from the health insurance payer. |
| EDI 278 | Healthcare provider or billing service | Health insurance payer | Requests prior authorization for specific healthcare services or procedures from the health insurance payer. |
| EDI 820 | Payer or employer | Healthcare provider or billing service | Transmits premium payments and associated remittance advice from the sender (payer or employer) to the healthcare provider or billing service. |
| EDI 824 | Receiver of the original transaction | Sender of the original transaction | Provides acknowledgment and notification of the status of an application or transaction. Confirms the receipt, acceptance, rejection, or pending status of the original transaction. |
| EDI 834 | Employer, benefits administrator, or health plan | Health insurance payer | Communicates enrollment and maintenance information, such as adding or terminating coverage, from the sender (employer, benefits administrator, or health plan) to the health insurance payer. |
| EDI 835 | Health insurance payer | Healthcare provider or billing service | Provides remittance advice and payment details from the health insurance payer to the healthcare provider or billing service for services rendered. |
| EDI 837-P | Healthcare provider or billing service | Health insurance payer | Submits professional healthcare claims for services rendered by healthcare providers such as physicians, therapists, and other professional services. |
| EDI 837-D | Dental care provider or billing service | Dental insurance payer | Submits dental healthcare claims for services provided by dental care providers. |
| EDI 837-I | Institutional healthcare provider or billing service (e.g., hospitals, nursing homes) | Health insurance payer | Submits institutional healthcare claims for services provided by hospitals, nursing homes, and other institutional facilities. |
| EDI 997 | Receiver of the original transaction | Sender of the original transaction | Functional acknowledgment indicating the receipt and basic validation of an EDI transaction. Confirms that the original transaction was received and whether it was accepted or rejected. |
| EDI 999 | Receiver of the original transaction | Sender of the original transaction | Implementation acknowledgment, providing detailed validation results for the original transaction. Specifies errors, warnings, or acceptances related to the received transaction. |
| TA1 | Receiver of the interchange (EDI file) | Sender of the interchange (EDI file) | Interchange |
Partner with PilotFish for Industry-Leading EDI Technology and Deep EDI Expertise
PilotFish’s X12 EDI Integration Solution is being leveraged by virtually every stakeholder in healthcare – including Payers, Data Analytics and Revenue Cycle providers, Channel Partners, Clearinghouses, EMR Vendors, Government Entities, HIEs, Hospitals, Medical Equipment & Device Manufacturers, Medical & Clinical Labs, Pharmacy Benefit Managers (PBMs), Solution Providers and Third Party Administrators (TPAs).
By embedding its deep knowledge of X12 schemas and standards into the PilotFish X12 EDI Integration Solution, PilotFish delivers breakthrough, productivity-boosting features. PilotFish’s built-in EDI functionality strips away the technical complexity of parsing, validating, mapping and producing X12 EDI files.
Partnering with PilotFish guarantees you the most comprehensive and innovative EDI support on the market, with advanced SNIP validation for types 1-7. With PilotFish, SNIP Levels 1-7 are validated via its exclusive stand-alone rules-driven EDI SNIP Validation Processor. You gain superior accuracy, efficiency and scalability with a streamlined validation process. The output results provide a standardized and structured format for downstream processing, ensuring accurate and consistent validation of EDI documents.
To sum up, PilotFish saves both time and lowers cost in healthcare by simplifying EDI transformations, automating repeatable tasks and significantly speeding up implementations and deployments.
Contact PilotFish today to discuss your use case and how PilotFish may meet your requirements.
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