Healthcare
EDI for Healthcare
Connecting providers and payers with HIPAA-mandated EDI
Business Process
End-to-End Healthcare EDI
From eligibility verification through claim submission, status tracking, and remittance — the complete healthcare revenue cycle.
EDI Process Flow
End-to-End Healthcare Claims Flow
From eligibility verification through claim submission, status tracking, and remittance — the complete healthcare revenue cycle.
The patient receives care once eligibility and benefits are confirmed.
Adjudication
Payment Posted
Business Flow
Systems Involved
Key Benefits of EDI
Want to understand this EDI flow?
Ask EDI AI →End-to-End Healthcare Claims Flow. Steps: Provider, Eligibility Inquiry, Payer / Health Plan, Eligibility Response, Service Rendered, Health Care Claim, Payer / Health Plan, Claim Status Request, Claim Status Response, Claim Payment / Remittance Advice, Provider.
Common EDI Transactions
The X12 and EDIFACT transaction sets that appear in this flow.
Eligibility, Coverage or Benefit Inquiry
The HIPAA X12 270 is a request from a healthcare provider to a payer asking whether a patient has active insurance coverage and what benefits apply.
Eligibility, Coverage or Benefit Information
The HIPAA X12 271 is the payer's response to a 270 inquiry, detailing whether the patient is covered and describing plan benefits, copays, and limitations.
Health Care Claim
The HIPAA X12 837 is the electronic claim a provider submits to a payer to request payment for services rendered (professional, institutional, or dental).
Health Care Claim Status Request
The HIPAA X12 276 asks a payer for the current processing status of a previously submitted health care claim.
Health Care Claim Status Response
The HIPAA X12 277 is the payer's answer to a 276, reporting where a claim stands in adjudication.
Health Care Claim Payment/Advice
The HIPAA X12 835 explains how a payer adjudicated a claim — what was paid, denied, or adjusted, and why — while optionally carrying the actual payment.
Systems Involved
EDI Standards
Step-by-Step Explanation
- 1
Provider
A trading partner in this flow.
- 2
Eligibility Inquiry (270)
Asks a payer whether a patient has active insurance coverage and what benefits apply.
- 3
Payer / Health Plan
A trading partner in this flow.
- 4
Eligibility Response (271)
Confirms coverage status and describes plan benefits, copays, and limitations.
- 5
Service Rendered
The patient receives care once eligibility and benefits are confirmed.
- 6
Health Care Claim (837)
Requests payment from a payer for services rendered to a patient.
- 7
Payer / Health Plan
Trading partner role: Adjudication.
- 8
Claim Status Request (276)
Asks a payer for the current processing status of a previously submitted claim.
- 9
Claim Status Response (277)
Reports where a claim stands in adjudication.
- 10
Claim Payment / Remittance Advice (835)
Explains how a payer adjudicated a claim — what was paid, denied, or adjusted, and why.
- 11
Provider
Trading partner role: Payment Posted.
Common EDI Documents
Business Benefits
- Verifies coverage before or at the point of service, reducing claim denials.
- Automates claims intake and adjudication in place of paper CMS-1500/UB-04 forms.
- Reduces payer call center volume by letting providers self-serve claim status checks.
- Speeds payment posting through automated 835 remittance matching.
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