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 the business functions supported by the X12 health care implementation guides. The intent of these diagrams is to represent the possible exchanges between trading partners using these implementation guides. Trading partners include entities that administer part or all of a health plan, fund the plan & enroll members, and provide the health care services. At the time of publication, transactions adopted under HIPAA are bolded.

These diagrams are intentionally simplified for presentation purposes. The transactions can be transmitted at various times in the care delivery cycle, not just the ones depicted. Similarly, other actors can and do send the transactions described in the diagrams for the same or similar purposes.

Enrollment/Maintenance Down Arrow

 

  1.   2.  
  Payer
834
     
 
 
 
 
 
  Sponsor
834
 
820
 

 

Help 1. Enrollment and Maintenance

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

Help 2. Premium Payment

820 Payroll Deducted and Other Group Premium Payment For Insurance Products

 

  3.  
  Payer
271
 
 
 
 
  Provider    

 

Help 3. Premium Period Grace Period Notification

271 Premium Period Grace Period Notification

Set-Up Down Arrow

  4.  
  Payer
275
 
 
 
 
  Payer
 
 

 

Help 4. Personal Health Record

275 Personal Health Record Transfer

 

  5.   6.   7.   8.  
  Payer
275
 
832
 
274
 
271
 
 
 
 
 
 
 
 
 
 
  Provider
275
     
274
 
 
 

 

Help 5. Personal Health Record

275 Personal Health Record Transfer

Help 6. Fee Schedule

832 Health Care Fee Schedule

Help 7. Participating Provider Directory (Roster)

274 Health Care Provider Directory

Help 8. Health Care Eligibility/Benefit Roster

271 Unsolicited Health Care Eligibility/Benefit Roster

 

  9.  
  Payer
834
 
 
 
 
  Agency
 
 

 

Help 9. 834 Plan Member Reporting

834 Plan Member Reporting

Pre-Health Care Delivery Down Arrow

 

  10.   11.   12.   13.   14.  
  Provider
270
 
278
275
 
278
 
278
 
 
 
 
 
 
 ↑    
 
 
 
 
 
 
 
  Payer
271
 
278
 
 
278
 
278
 
274
 

 

Help 10. Eligibility

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

Help 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

Help 12. Health Care Services Review Inquiry

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

Help 13. Health Care Services Review Notification

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

Help 14. Provider Information

274 Health Care Provider Information

Post-Health Care Delivery Down Arrow

 

  15.   16.   17.   18.   19.  
  Provider
837
275
 
276
 
275
 
 
 
 
 
 
 ↑    
 
 
 
 
 
 
 
 
 
  Payer
277
 
 
277
 
277
 
277
 
835
 

 

Help 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

Help 16. Health Care Claim Status

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

Help 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

Help 18. Health Care Claim Pending Status

277 Health Care Claim Pending Status Information

Help 19. Health Care Claim Payment

835 Health Care Claim Payment/Advice

 

  20.   21.  
  Payer
837
 
269
 
 
 
 
 
 
  Payer
 
 
269
 

 

Help 20. Coordination of Benefits/Subrogation

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

Help 21. Health Care Benefit Coordination Verification

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

 

  22.  
  Payer
837
 
 
 
 
  Agency
 
 

 

Help 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