EDI Transaction Functional Group GS*

EDI Transactions Transactions Name BHT GS ST Other information

837 Claim& Encounter- 019-Source HC-Health 837 Submitter 41, Receiver 40, Hierarchy HL Billing provider 85, Subscriber IL, Payer PR, Patient QC, Claim
P-Professional Information Claim CLM, Diagnosis Code HI-ABK, ABF,ABJ, APR, Procedure code HI-BBR, BBQ, Rendering provider 71,
WIT=90-B-SV1 BHT06-CH: Claim Referring Provider DN, Operating provider 72, other Operating Provider 82, Facility Location 77, Line
I-Institutional /Encounter number LX, Service line SV1/SV2, Statement Date 434, Date of service 472, Admission Date 435, Discharge
WIT=84/85-A-SV2 Indicator Date 096, Remittance Date 573
835 Electronic Remittance BPR-Beginning HP-Health 835 Submitter GS02, Payer ID GS03, Payee PE, Claim payment CPL, Claim status code CPL02-1 processed as
Advice/ERA- a document segment for Care primary-2 processed as secondary-4 denied-22 reversal/previous payment, CPL07 Claim number, Patient
supplied by insurance Remittance advice Payment name QC, rendering provider 71, Service payment information SVC, Service Adjustments CAS, Payer paid
payer to provider /patient I-Check/ACH advice amount, allowed amount, approved amount, patient responsibility (Deductible, Copay and Coinsurance),
H-Zero Payment Submitter Discount amount, adjudication date, check number, remark explanation.
ID-GS02
834 Benefit enrollment and BGN: 00 Original, PO- The 834 transaction may be used for any of the following functions relative to health plans: New
maintenance 15-Resumbission enrollments-Changes in a member’s enrollment-Reinstatement of a member’s enrollment-Disenrollment
of members (i.e., termination of plan membership). A typical 834 document may include the following
information: Subscriber name and identification, Plan network identification, Subscriber eligibility and/or
benefit information, Product/service identification.
Plan sponsor P5, Insurer INS, Subscriber number OF, Group policy# 1L

820 Remittance BPR-Beginning RA- 820 Remittance Advice/Payment order- includes payer and payee identification, bank and account IDs, invoice
Advice/Payment order segment for Remittance number(s), adjustments from an invoice, billed and paid amounts. This information allows the suppliers
Remittance advice Advice and health plans to reconcile payments they receive against invoices they have issued.
I-Check/ACH
H-Zero Payment
270 Eligibility Request- 022- Information HS-Eligibility 270 Information source PR (Payer), Information receiver FA (Facility), 1P (Professional provider), Subscriber
Eligibility and benefit source inquiry information IL, Subscriber eligibility inquiry information EQ
quotes include BHT02-13 Request
membership verification,
coverage status and other
important information,
such as applicable
copayment, coinsurance
and deductible amounts.
271 Eligibility Response 022- Information HB-Eligibility 271 Information source PR (Payer), Information receiver FA (Facility), 1P (Professional provider), Subscriber
source response information IL, REF-6P Group number, 356 (Eligibility Begin) 357 (Eligibility End) 472 (Date of Service).
BHT02-11 Patient/Subscriber information: Group Number, Group Name, Plan/Product, Current Effective Dates,
Response Copayment*, Deductible (original and remaining amounts), Out-of-pocket (original and remaining
amounts), Coinsurance, Limitations/Maximums* Preauthorization indicators and contacts

276 Claim status request HR-Claim 276 The transaction typically includes: Provider identification, Patient identification, Subscriber information,
status Date(s) of service(s), Charges
request
277 Claim status response HN-response 277 Payer Name: NM1*PR, Information Receiver Name: NM1*41, Provider Name: NM1*1P, Demographic
Information: DMG ,Patient Name: NM1*QC, Trace: TRN*, Status Information: STC*P3:60,, Reference
Information: REF*BLT*221, Service Information: SVC*HC, Status Information: STC*F1:65