Health Care Transaction Flow

Each X12 implementation guide explains how to use X12 transaction sets to meet a single defined business purpose. The following diagrams depict various exchanges between trading partners based on the implementation guides developed within the X12’s Insurance subcommittee (X12N). Trading partners for these exchanges include health plans, health care service providers, and other entities that administer health plan services, fund health plans, or enroll members. Some of these transactions have been adopted under HIPAA and those are bolded.

The diagrams are intentionally simplified for presentation purposes. The transactions can be transmitted at various times in the care delivery cycle, not just in the order depicted here. Similarly, other trading partners can and do exchange the transactions described in the diagrams for the same or similar purposes.

Enrollment/Maintenance
  1.   2.  
  Payer
834
     
 
 
 
 
 
  Sponsor
834
 
820
 

1. Enrollment and Maintenance 

834 Benefit Enrollment and Maintenance
(Including a separate implementation guide for Health Insurance Exchanges)

The Benefit Enrollment and Maintenance Implementation Guide describes the use of the X12 Benefit Enrollment and Maintenance (834) transaction set and addresses the enrollment and maintenance of human resources benefit plans including:

  • Tier-based coverage (medical, dental and vision)
  • Tax advantage accounts (flexible spending accounts, healthcare spending accounts, and healthcare reimbursement accounts)
  • Rate-based coverage (life, short term disability and long term disability)

2. Premium Payment

820 Payroll Deducted and Other Group Premium Payment For Insurance Products

The Payroll Deducted and Other Group Premium Payment for Insurance Products Implementation Guide describes the use of the X12 Payment Order/Remittance Advice (820) transaction set for the following business usage:

  • Transmit payroll deducted premiums for a wide variety of insurance products, to include life, health, property and casualty, and disability.
  • This guide was also designed for health care premium payments between federal and state governments, government agencies, and private industry.
  3.  
  Payer
271
 
 
 
 
  Provider    

3. Premium Period Grace Period Notification

271 Premium Period Grace Period Notification

The Premium Payment Grace Period Notification Implementation Guide describes the use of the X12 Eligibility, Coverage or Benefit Information (271) transaction set for reporting Health Insurance Exchange (HIX) Premium Payment Grace Period, other (non-HIX) premium payment grace periods, and related information from health plans to providers.

Set-Up
  4.  
  Payer
275
 
 
 
 
  Payer
 
 

4. Personal Health Record

275 Personal Health Record Transfer

The Personal Health Record Transfer Implementation Guide describes the use of the ASC X12 Patient Information (275) transaction set for the following business usage:

  • To transfer Personal Health Record (PHR) information.

The business flows supported by this implementation are the following:

  • When an employer or coverage sponsor changes from one health plan to another, the new health plan may request the prior plan to transfer PHR information of those covered individuals
  • When an individual changes jobs and elects coverage under a new health plan, they may request the transfer of PHR information for covered individuals. The prior health plan, with the individual's authorization, will transfer the PHR information to the new health plan.
  • When an individual or subgroup of individuals changes from one health plan to another, the new health plan may request the prior health plan to transfer the PHR information of those covered individuals.
  5.   6.   7.   8.  
  Payer
275
 
832
 
274
 
271
 
 
 
 
 
 
 
 
 
 
  Provider
275
     
274
 
 
 

5. Personal Health Record

275 Personal Health Record Transfer

The Personal Health Record Transfer Implementation Guide describes the use of the ASC X12 Patient Information (275) transaction set for the following business usage:

  • To transfer Personal Health Record (PHR) information.

6. Fee Schedule

832 Health Care Fee Schedule

The Health Care Fee Schedule Implementation Guide describes the use of the Price/Sales Catalog (832) transaction set for the following business use:

  • Send a health care fee schedule from a health plan to a provider

7. Participating Provider Directory (Roster)

274 Health Care Provider Directory

The Health Care Provider Information Implementation Guide describes the use of the Provider Information (274) Transaction Set for the following business usages:

  • Send an application for membership to a health care entity
  • Send registration information to a health care entity
  • Send a health care entity's limited response to the health care provider

8. Health Care Eligibility/Benefit Roster

271 Unsolicited Health Care Eligibility/Benefit Roster

The Unsolicited Health Care Eligibility/Benefit Roster Implementation Guide describes the use of the X12 Eligibility, Coverage or Benefit Information (271) Version/Release 005010 transaction set for the unsolicited request for the following roster types:

  • Capitation payment detail
  • Membership list
  • Plan (coverages)
  • Group (employer)
  • Provider
  9.  
  Payer
834
 
 
 
 
  Agency
 
 

9. 834 Plan Member Reporting

834 Plan Member Reporting

The Plan Member Reporting Implementation Guide describes the use of the X12 834 transaction set for reporting plan members and member related information, which may or may not be available on a claim transaction, to All Payers Claims Databases for the purpose of enhancing health data reporting.

Pre-Health Care Delivery
  10.   11.   12.   13.   14.  
  Provider
270
 
278
275
 
278
 
278
 
 
 
 
 
 
 ↑    
 
 
 
 
 
 
 
  Payer
271
 
278
 
 
278
 
278
 
274
 

10. Eligibility

270 Health Care Eligibility Benefit Inquiry
271 Health Care Eligibility Benefit Information Response

The Health Care Eligibility/Benefit Inquiry and Information Response Implementation Guide describes the use of the Eligibility, Coverage or Benefit Inquiry (270) transaction set and the Eligibility, Coverage, or Benefit Information (271) transaction set for the following business usages:

  • Determine if an Information Source organization, such as an insurance company, has a particular subscriber or dependent on file
  • Determine the details of health care eligibility and/or benefit information

11. Health Care Services Review Request

278 Health Care Services Review – Request for Review
278 Health Care Services Review – Response

275 Additional Information to Support a Health Care Services Review

The Health Care Services Review Request and Response Implementation Guide describes the use of the X12 Health Care Services Review Information (278) transaction set for the following business usages:

  • Health care admission certificate requests and responses
  • Referral requests and responses
  • Health care services certification requests and responses
  • Extend certification requests and responses
  • Certification appeal requests and responses

The Additional Information to Support a Health Care Services Review Implementation Guide describes the use of the X12 Patient Information (275) transaction set for the following business usage:

  • To assist those who send additional supporting information or who receive additional supporting information to a health care claim services review.

12. Health Care Services Review Inquiry

278 Health Care Services Review Inquiry
278 Health Care Services Review Response

The Health Care Services Review Inquiry and Response Implementation Guide describes the use of the X12 Health Care Services Review Information (278) transaction set for the following business usages:

  • Make inquiries to utilization management organizations for information on previously processed health care services
  • Send response(s) to inquiry(ies) on previously processed health care services

13. Health Care Services Review Notification

278 Health Care Services Review Notification
278 Health Care Services Review Acknowledgment

The Health Care Services Review - Notification Implementation Guide describes the use of the X12 Health Care Services Review Information (278) transaction set for the following business usage: Notification of interested parties concerning events related to a health care services review such as:

  • Patient arrival notice
  • Patient discharge notice
  • Patient transfer notice
  • Notification of certification to primary care physcian (PCP), utilization management organization (UMO), or other service providers
  • Certification notice change

14. Provider Information

274 Health Care Provider Information

The Health Care Provider Directory Implementation Guide describes the use of the X12 Provider Information (274) transaction set, for the following business usage:

  • Transmit provider directory information
Post-Health Care Delivery
  15.   16.   17.   18.   19.  
  Provider
837
275
 
276
 
275
 
 
 
 
 
 
 ↑    
 
 
 
 
 
 
 
 
 
  Payer
277
 
 
277
 
277
 
277
 
835
 

15. Health Care Claim and Encounter plus Additional Supporting Information

Provider initiated coordination of benefits occurs here
837 Health Care Claim: Professional
837 Health Care Claim: Institutional
837 Health Care Claim: Dental

837 Health Care Service Data Reporting
277 Health Care Claim Acknowledgment
275 Additional Information to Support a Health Care Claim or Encounter

The Health Care Claim: Professional, Institutional, and Dental Implementation Guides describe the use of the X12 Health Care Claim (837) transaction set to submit and transfer claims and encounters to primary, secondary, and subsequent payers.

The Health Care Service: Data Reporting Implementation Guide describes the use of the X12 Health Care Claim (837) transaction set for the following business usages:

  • Reporting health care service data for use in health data statistical analysis from provider
  • Reporting health care service data to satisfy governmental mandates necessary to regulate the health care industry
  • Reporting health care service data to measure utilization rates

The Additional Information to Support a Health Care Claim or Encounter Implementation Guide describes the use of the X12 Patient Information (275) transaction set for the following business usage:

  • To assist those who send additional supporting information or who receive additional supporting information to a health care claim or encounter.

The Health Care Claim Acknowledgment Implementation Guide describes the use of the X12 Health Care Information Status Notification (277) transaction set to acknowledge receipt of electronically submitted claim data and indicate the data's acceptance, rejection or forwarding to another entity.

16. Health Care Claim Status

276 Health Care Claim Status Request
277 Health Care Claim Status Response

The Health Care Claim Status Request and Response Implementation Guide describes the use of the X12 Health Care Claim Status Request (276) transaction set and the X12 Health Care Information Status Notification (277) transaction set to request the status of health care claim(s) and respond with information regarding the specified claim(s).

17. Health Care Claim Additional Information

277 Health Care Claim Request for Additional Information
275 Additional Information to Support a Health Care Claim or Encounter

The Health Care Claim Request for Additional Information Implementation Guide describes the use of the X12 Health Care Information Status Notification (277) transaction set to request additional information to support a health care claim or encounter.

The Additional Information to Support a Health Care Claim or Encounter Implementation Guide describes the use of the X12 Patient Information (275) transaction set for the following business usage:

  • To assist those who send additional supporting information or who receive additional supporting information to a health care claim or encounter.

18. Health Care Claim Pending Status

277 Health Care Claim Pending Status Information

The Health Care Claim Pending Status Information Implementation Guide describes the use of the X12 Health Care Information Status Notification (277) transaction set to provide claim status information on claims pending in the payer's adjudication system without requiring health care provider solicitation.

19. Health Care Claim Payment

835 Health Care Claim Payment/Advice

The Health Care Claim Payment/Advice Implementation Guide describes the use of the ASC X12 Health Care Claim Payment/Advice (835) transaction set for the following business usages:

  • Make payment on a health care claim
  • Send an Explanation of Benefits (EOB) remittance advice
  • Make payment and send an EOB in the same transaction
  20.   21.  
  Payer
837
 
269
 
 
 
 
 
 
  Payer
 
 
269
 

20. Coordination of Benefits/Subrogation

837 Health Care Claim: Professional
837 Health Care Claim: Institutional
837 Health Care Claim: Dental

The Health Care Claim: Professional, Institutional, and Dental Implementation Guides describe the use of the X12 Health Care Claim (837) transaction set to submit and transfer claims and encounters to primary, secondary, and subsequent payers to assist with coordination of benefits processing.

21. Health Care Benefit Coordination Verification

269 Health Care Benefit Coordination Verification Request
269 Health Care Benefit Coordination Verification Response

The Health Care Coordination of Benefits Request and Response Implementation Guide describes the use of the X12 Health Benefit Coordination Verification (269) transaction set for the following business usage:

  • Payer to payer coordination of benefits verification request and response
  22.  
  Payer
837
 
 
 
 
  Agency
 
 

22. Post-adjudicated Claims Data Reporting

837 Post Adjudicated Claims Data Reporting: Professional
837 Post Adjudicated Claims Data Reporting: Institutional
837 Post Adjudicated Claims Data Reporting: Dental

The Post Adjudicated Claims Data Reporting: Implementation Guides describe the use of the X12 Health Care Claim (837) transaction set for reporting health care professional, institutional, and dental service post adjudicated data:

  • To satisfy state and federal reporting requirements such as; Medicare and Medicaid encounters, All Payer Claims Databases, and Health Care Insurance Exchanges
  • For use in health data analysis from payer data