Transaction and Code Sets

EDI Transaction

HIPAA Mandated Uses

270/271 - Eligibility/ Benefit inquiry and response

The eligibility for a health plan transaction is the transmission of either of the following:

1. 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:
   
   1. Eligibility to receive health care under the health plan.
   2. Coverage of health care under the health plan.
   3. Benefits associated with the benefit plan.
2. A response from a health plan to a health care provider’s (or another health plan’s) inquiry described in paragraph (a) of this section

276/277 - Claim status request and response

A health care claim status transaction is the transmission of either of the following:

1. An inquiry to determine the status of a health care claim.
2. A response about the status of a health care claim.

278 - Referral certification and authorization

The referral certification and authorization transaction is any of the following transmissions:

1. A request for the review of health care to obtain an authorization for the health care.
2. A request to obtain authorization for referring an individual to another health care provider.
3. A response to a request described in paragraph (a) or paragraph (b) of this section.

820 - Health plan premium payment

The health plan premium payment transaction is the transmission of any of the following from the entity that is arranging for the provision of health care or is providing health care coverage payments for an individual to a health plan:

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

834 - Enrollment and disenrollment

The enrollment and disenrollment in a health plan transaction is the transmission of subscriber enrollment information to a health plan to establish or terminate insurance coverage.

835 - Claim payment and remittance advice

The health care payment and remittance advice transaction is the transmission of either of the following for health care:

1. The 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.
2. The transmission of either of the following from a health plan to a health care provider:
   1. Explanation of benefits and
   2. Remittance advice.

837 - Health care claim (Professional, institutional, and dental)

The health care claims or equivalent encounter information transaction is the transmission of either of the following:

1. A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.
2. 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.
   • 837 Professional is the adopted standard for professional health care claims or equivalent encounter information.
   • 837 Institutional is the adopted standard for institutional health care claims.
   • 837 Dental is the adopted standard for dental claims.

837 - Coordination of benefits

The coordination of benefits transaction is the transmission from any entity to a health plan for the purpose of determining the relative payment responsibilities of the health plan, of either of the following for health care:

1. Claims
2. Payment information