Real-World EDI Examples in Healthcare
For developers, system architects, and IT leaders in the healthcare space, understanding EDI standards and optimizing their use continues to be essential for maintaining effective and scalable systems. Let’s take a closer look at how EDI actually looks “under the hood.” These examples represent typical data flows between healthcare providers and payers.
837: Healthcare Claim (Professional)
This transaction is used by healthcare providers to submit billing claims to insurers.
ISA*00* *00* *ZZ*123456789 *ZZ*987654321 *240503*1230*^*00501*000000905*0*T*:~
GS*HC*123456789*987654321*20240503*1230*905*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*0123*20240503*1230*CH~
NM1*41*2*PROVIDER CLINIC*****46*1234567890~
PER*IC*JANE DOE*TE*5551234567~
NM1*40*2*INSURANCE COMPANY*****46*999888777~
HL*1**20*1~
NM1*85*2*PROVIDER CLINIC*****XX*1234567893~
N3*123 MAIN STREET~
N4*CITY*ST*12345~
…
CLM*ABC12345*150***11:B:1*Y*A*Y*I~
HI*BK:25000~
LX*1~
SV1*HC:99213*100*UN*1***1~
SE*23*0001~
GE*1*905~
IEA*1*000000905~
What’s happening here:
- The provider submits a claim (`CLM` segment) for \$150 for CPT code 99213.
- The `HI` segment shows the diagnosis code (ICD).
- This data feeds directly into the payer’s claims adjudication system.
835: Remittance Advice
After a claim is processed, the payer sends an 835 to explain the outcome – what was paid, denied, or adjusted.
ISA*00* *00* *ZZ*999888777 *ZZ*123456789 *240503*1300*^*00501*000000123*0*T*:~
GS*HP*999888777*123456789*20240503*1300*123*X*005010X221A1~
ST*835*0001*005010X221A1~
BPR*I*100.00*C*ACH*CCP*01*999999999*DA*123456789*1512345678*20240503~
TRN*1*1234567890*9876543210~
N1*PR*INSURANCE COMPANY*XX*999888777~
N1*PE*PROVIDER CLINIC*XX*1234567893~
CLP*ABC12345*1*150.00*100.00*50.00*MC*1234567890*11*1~
CAS*CO*45*50.00~
NM1*QC*1*DOE*JOHN****MI*987654321~
DTM*232*20240428~
SE*23*0001~
GE*1*123~
IEA*1*000000123~
Key takeaways:
- The `CLP` segment shows that the claim `ABC12345` was submitted for \$150, with \$100 paid and \$50 adjusted.
- The `CAS` segment details the adjustment reason (e.g., contractual obligation).
- The `BPR` segment contains payment info for automated funds transfer (ACH).
Helpful Tips for Working with EDI in Healthcare
- Use EDI parsers or libraries to convert raw data into structured formats (JSON/XML) for internal systems.
- Validate segments against the official X12 implementation guides (e.g., 005010X222 for 837P).
- Implement acknowledgment handling (e.g., 999 or 277CA) to track whether claims were received and accepted.
Whether you’re building custom integrations, optimizing revenue cycle workflows, or improving interoperability in healthcare IT, understanding EDI formats like 837 and 835 is essential. These aren’t just “old-school” protocols—they’re foundational to modern healthcare operations, and they continue to evolve alongside digital transformation efforts.
To learn more about EDI and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.