X12 EDI Healthcare Transactions Decoded: Who Sends, Who Receives and Why

Throughout the healthcare ecosystem, patient encounters trigger X12 EDI transactions involving insurance benefits, claims and payment. Senders and receivers of EDI transactions range from healthcare providers, professionals and institutions, clearinghouses, employers and insurance companies to government entities such as Medicare. Additionally, HIPAA (Health Insurance Portability and Accountability Act) mandates healthcare organizations follow specific X12 EDI standards to submit and process 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, coordination of benefits, claims and payment status as well as payer specifics.

Critical to healthcare today, X12 EDI data integration helps ensure interoperability between all upstream and downstream participants in the process.

CHART: X12 EDI Healthcare Information Exchange Transactions
and Participants

PilotFish created this user-friendly chart as a “cheat sheet” 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.

The EDI transactions used in Healthcare Eligibility & Benefits, Claims Management, Payments & Remittances, Enrollment & Maintenance are delineated. 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 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 the X12 schemas and standards within 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 support of any product on the market for EDI with advanced SNIP validation of 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 have a discussion regarding your use case and how PilotFish may meet your requirements.

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.