EDI Transactions medicare

Steps of an EDI Transaction: United Healthcare Scenario Example

EDI transactions start with an inquiry from the care provider and conclude with a response from the payer. The inquiry is submitted by supplying certain required data fields, such as member ID number, date of birth and Payer ID. This inquiry can go directly to the payer, but it often goes through a clearinghouse contracted by the care provider. The clearinghouse facilitates the inquiry to the payers. Once the payer receives the inquiry, they send the response back to the clearinghouse. The clearinghouse then sends the data to the care provider’s practice management system. If there’s an error in the data, the care provider will correct it and resubmit it to the clearinghouse for a response. EDI transactions can be completed for one or more members.

Sample scenario of how EDI works

A medical group is scheduled to see 100 patients from various payers on a Tuesday. They want to verify coverage and know how much to collect before the appointments. Using the 270 transaction for the inquiry for eligibility and benefit information, the payer returns the 271 transaction as the response. For this example, here’s what would happen:

  • The care provider’s practice management system compiles the required information for the patients who have appointments on Tuesday.
  • The 270 inquiry transaction goes to the clearinghouse, which sends the 270 transaction to each payer.
  • The payer returns a 271 response transaction with confirmation of coverage/eligibility, copayment, coinsurance and deductible information and other benefit details.
  • The 271 transaction is returned to the clearinghouse for formatting and transmitted into the care provider’s practice management system.
  • On Tuesday morning, the care provider staff sees confirmation of coverage and the cost sharing amounts on their computers before the patient arrives.
  • If there were errors with any 270 transaction requests, the information can be corrected in the care provider’s practice management system and resubmitted for an immediate response.
  • If the care provider needs more information than the EDI transaction provides, they can use the Link selfservice tools to get additional information.

To learn more about Healthcare EDI transactions and become a certified EDI Professional please visit our course schedule page.

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