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

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Enrollment

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

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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

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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

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Eligibility Response

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

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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.

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Coordination of Benefits Transaction

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

• Health care claims, or
• Health care payment information

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

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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 providers 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

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Claim Status Inquiry

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

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Claim Status Response

Numerical Identifier: 277
A response to a Claim Status Inquiry.

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