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EDI Transaction Standards

Text in Blue shows the receiver of the transaction. Text in Orange shows the sender of the transaction. Some transactions do not define a specific sender and/or receiver.



Enrollment

Numerical identifier: 834
Transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.



Premium payment

Numerical identifier: 820
Transmission of any of the following to a health plan from the entity that is arranging for the provision of health care coverage payments or is providing health care coverage payment for an individual:

  • Payment
  • Information about the transfer of funds
  • Detailed remittance information about individuals for whom premiums are being paid
  • Payment processing information to transmit health care premium payments including any of the following:
  1. Payroll deductions
  2. Their group premium payments
  3. Associated group premium payment information

Eligibility inquiry

Numerical identifier: 270
An inquiry from a health care provider to a health plan, or from one health plan to another health plan, to obtain any of the following information about a benefit plan for an enrollee:

  • Eligibility to receive health care under the health plan
  • Coverage of health care under the plan
  • Benefits associated with the health plan



Eligibility response

Numerical Identifier: 271
A response from a health plan to health care providers (or another health plan). Eligibility Inquiry (270 defined above).



Claim/encounter transaction

Numerical Identifier: 837
A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.

If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.



Coordination of benefits transaction

Numerical Identifier: 837 COB
Transmission from any entity to a health plan:

  • Health care claims, or
  • Health care payment information

For the purpose of determining the relative payment responsibilities of the health plan.



Remittance advise (explanation of benefits)

Numerical Identifier: 835
Transmission of either of the following for health care:

  • Transmission of any of the following from a health plan to a health care provider's financial institution:
    1. Payment
    2. Information about the transfer of funds
    3. Payment processing information
  • Transmission of either of the following from a health plan to a health care provider:
    1. Explanation of benefits
    2. Remittance advice



Claim status inquiry

Numerical identifier: 276
An inquiry to determine the status of a health care claim.