Sending Healthcare Claim Attachments via EDI: A Technical Guide with Examples
In healthcare EDI, claim attachments play a vital role in providing additional documentation that supports the adjudication of claims. Whether you’re dealing with X-rays, lab reports, or itemized bills, transmitting these documents electronically through the ASC X12N 275 transaction set helps reduce delays, streamline communication, and maintain HIPAA compliance.
In this blog, we’ll walk through how claim attachments are sent via EDI—specifically using the 275 transaction—and how it complements a healthcare claim such as the 837.
Why Use the 275 Claim Attachment?
Payers often require documentation to support certain procedures or services, particularly for dental, DME, or high-cost procedures. Without timely attachments, claims may be pended or denied.
The 275 transaction allows providers to:
- Submit attachments after sending the 837 claim (unsolicited).
- Respond to payer requests for additional info (solicited).
Unsolicited Claim Attachment Example
Let’s say you submitted an 837P (Professional Claim) and expect the payer to request a pre-op report. Here’s how you’d format the unsolicited attachment using EDI 275:
ISA*00* *00* *ZZ*SUBMITTERID *ZZ*RECEIVERID *240509*1430*^*00501*000000905*1*T*:~
GS*XO*SUBMITTERID*RECEIVERID*20240509*1430*905*X*005010X210~
ST*275*0001*005010X210~
BGN*01*275001*20240509*1430*PT~
HL*1**20*1~
NM1*41*2*MY HEALTH CLINIC*****46*1234567890~
HL*2*1*21*1~
NM1*40*2*INSURANCE COMPANY*****46*9988776655~
HL*3*2*19*0~
NM1*IL*1*DOE*JOHN****MI*123456789~
REF*F8*8371234567~
DTP*472*D8*20240507~
LX*1~
ATX*AF*REPORT TYPE~
REF*E9*PREOP-2024~
BIN*AA*application/pdf*base64~
BDS*JVBERi0xLjQKJeLjz9MKNCAwIG9iago8PC9MaW5lYXJpemVkIDEvT… (truncated base64 PDF)~
SE*18*0001~
GE*1*905~
IEA*1*000000905~
Key Segments Explained:
REF*F8*8371234567~: Links this attachment to a previously submitted 837 claim.
BIN*AA*application/pdf*base64~ and BDS…~: Encodes the PDF document.
REF*E9*PREOP-2024~: Identifier for the attachment type (e.g., pre-op report).
Solicited Attachments (Optional Support)
If a payer sends a request for additional info (e.g., via 277), the same 275 transaction can be used to respond. The main difference is the presence of specific control numbers and the original payer’s request ID. Not all payers support solicited attachments in real-time. Check payer-specific implementation guides.
Best Practices
- Use base64 encoding for binary files like PDFs or images.
- Link to the original claim using `REF*F8` and trace numbers.
- Limit size: Large files can trigger transmission errors; some clearinghouses enforce limits.
- Automate: Use an API or EDI translator to handle base64 encoding and manage acknowledgments (e.g., TA1, 999).
Using EDI 275 for healthcare claim attachments speeds up reimbursements and minimizes manual faxing or portal uploads. For a full implementation, make sure your EDI clearinghouse or API provider supports X12 275 transactions and that you’re aligned with your trading partner’s attachment requirements.
To learn more about EDI and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.