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EDI transactions and code sets

HIPAA has national standards for health care Electronic Data Interchange (EDI) transaction and code sets. These standards support consistency in electronic exchange of data among providers, health care plans, clearinghouses, vendors and other health care business associates. The following dropdowns provide more detailed information about each transaction type.

Learn more about EDI

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Use the Eligibility and Benefit Inquiry (270) transaction to inquire about the health care eligibility and benefits associated with a subscriber or dependent.

Use the Eligibility and Benefit Response (271) transaction to respond to a request inquiry about the health care eligibility and benefits associated with a subscriber or dependent.

You can obtain detailed benefit information including member ID number, date of coverage, copayment, year-to-date deductible amount, and commercial coordination of benefit (COB) information when applicable. Physicians and other health care professionals can perform eligibility (270/271) transactions in batch or real-time mode, based on your connectivity method.

Benefits

  • Reduces collection and billing costs
  • Decreases bad debt
  • Improves cash flow
  • Increases productivity and efficiency
  • Results in fewer rejected claims
  • Lessens time spent on manual, administrative tasks
  • Expedites reimbursement
  • Available to participating and non-participating health care professionals

Getting started


Please contact your software vendor or clearinghouse. If available, eligibility transactions may be integrated into your practice management system or hospital information system. This allows systems to automatically generate an inquiry and/or to enable automatic posting of the benefit information to patient accounts.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time eligibility solutions.

Use the Additional Information to Support a Health Care Claim or Encounter (275) transaction to submit additional information related to a claim, instead of using mail or fax.

Solicited attachments are provided as a response to a Health Care Claim Request for Additional Information (277), a paper request or another method of request for additional information.

Unsolicited attachments are provided without a request and can be submitted for claims or encounters that are likely to result in a request for additional information.

Two ways to send information

  • Directly from practice to payer
  • From practice to clearinghouse to payer

Benefits

  • Provides electronic acknowledgment and proof of delivery/receipt
  • Eliminates requests from us for supporting documentation
  • Removes the need to copy and mail information
  • Cuts out the need to drop claims to paper when attachments are needed
  • Prevents added delays by allowing submission of additional information needed at the time of claim submission
  • Increases productivity and efficiency

Getting started


We want to make working with us easier, which includes the ability to submit all the information electronically.

Current EDI 275 availability

In partnership with our affiliate, Optum, we’re working to add more clearinghouses that can accept solicited and unsolicited EDI 275 claim attachments.

The following clearinghouses have unsolicited attachment capabilities:

  • Jopari
  • Quadax
  • Claim M.D.
  • Experian
  • Xifin

If your organization is currently working with one of these clearinghouses, please contact them directly to get started.

Companion guides

Additional resources

  • Claims, billing and payments page: Get more details on uploading supporting documentation for all claims to the UnitedHealthcare Provider Portal
  • EDI support: Contact EDI Support for issues, questions or information not found online

Use the Claim Status Inquiry (276) transaction to inquire about the status of a claim after it has been sent to a payer, whether submitted on paper or electronically.

Use the Claim Status Response (277) to respond to a request inquiry about the status of a claim after it has been sent to a payer, whether submitted on paper or electronically.

Once we return an acknowledgment that a claim has been accepted, it should be available for query as a claim status search. Physicians and other health care professionals can perform claim status (276/277) transactions in batch or real-time mode, based on your connectivity method.

Benefits

  • Increases productivity and efficiency
  • Lessens time spent on manual, administrative tasks
  • Decreases duplicate claim submissions
  • Improves cash flow
  • Available for participating and non-participating health care professionals

Getting started


Please contact your software vendor or clearinghouse. If available, eligibility transactions may be integrated into your practice management system or hospital information system. This allows systems to automatically generate an inquiry and/or to enable automatic posting of the status information to patient accounts.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time claim status solutions.

Use the Authorization and Referral Request (278) transaction to electronically submit authorization and referral requests. An authorization is a review of services related to an episode of care, and a referral is used to refer a member to a specialty provider.

These transactions can be submitted in real time or batch mode. Confirmation numbers are returned to validate receipt of request.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Accomplishes more with less — fewer phone calls, faxes or keying

Getting started


Please contact your software vendor or clearinghouse. If available, authorization and referral request transactions may be integrated into your practice management system or hospital information system. This allows systems to automatically generate an inquiry and/or to enable automatic posting of the authorization or referral information to patient accounts.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time solutions.

Additional resources

The Prior Authorization and Notification page contains information on our care management program, quick reference guides and other tools to support your success with this process.

Use the Prior Authorization and Notification Inquiry (278I) transaction to check the status of previously submitted authorizations and notifications. Electronic authorization and notification inquiries can be submitted in real time or batch mode, and you’ll receive a unique inquiry ID for confirmation of submission.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Accomplishes more with less — fewer phone calls, faxes or keying

Getting started


Please contact your software vendor or clearinghouse. Most clearinghouses already send 278I transactions to UnitedHealthcare and can work with you to submit in the appropriate format.

Additional resources

The Prior Authorization and Notification page contains information on our care management program, quick reference guides and other tools to support your success with this process.

Use the Hospital Admission Notification (278N) transaction to exchange admission notification data between an inpatient facility and UnitedHealthcare in a standard format.

Similar to the HIPAA 278 transaction that you may already use to submit authorizations or referrals, the EDI 278N is the easiest, most-efficient way to communicate facility admissions. It can be transmitted directly to UnitedHealthcare or through a clearinghouse in either batch or real-time format.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Confirms a notification of admission is on file (service reference number generated upon registration)
  • Submits notification of discharge

Getting started


Please contact your software vendor or clearinghouse. Most clearinghouses already send 278N transactions to UnitedHealthcare and can work with you to submit in the appropriate format.

Use the Electronic Remittance Advice (ERA), or 835, transaction to receive additional claim payment information. These files are used by practices, facilities and billing companies to auto-post claim payments into their systems. You can receive your 835 files through your clearinghouse, direct connection or by downloading them through Optum Pay®, found in the UnitedHealthcare Provider Portal.

Benefits

  • Allows you to receive 835 files directly in your practice management or hospital information system
  • Increases data accuracy by reducing manual errors
  • Streamlines administrative tasks and boosts productivity

Getting started

  • Please contact your software vendor or clearinghouse to request direct delivery of your UnitedHealthcare 835 files. Once we receive the request from your vendor/clearinghouse, it takes about 30 days to set up ERA/835 delivery.
  • Sign up for Optum Pay to enjoy faster payments through direct deposit through your bank account and printable online explanation of benefits (EOBs) on demand. Note: If you don’t enroll in Optum Pay, you’ll receive consolidated 835 files (a file for each check you receive) and continue to receive paper EOBs in the mail.

Definitions and acronyms

  • ACH, EFT: Automated Clearing House (ACH) is used interchangeably with electronic funds transfer (EFT). ACH allows payment through the electronic transfer of funds into a bank account that the customer designates.
  • EFT 835: The UnitedHealthcare “EFT 835” is a HIPAA-format file ASC X12 combined 005010X221 and 005010X221A1 standard that may merge multiple individual 835s sent on the same day by tax ID number (TIN) or National Provider Identifier (NPI) number. The
  • EFT 835 ties to the ACH payment for that day’s EPS/Optum Pay deposit to your bank account. This facilitates receipt and tracking of payment for multiple claims.
  • EOB, PRA: Explanation of benefits (EOBs) are sometimes called provider remittance advice (PRA) and are typically in paper form.
  • EPRA: The electronic provider remittance advice (EPRA) is a document that resembles a provider EOB/PRA that is created from the data provided in the EFT 835.
  • EPS: Electronic payments and statements (EPS/Optum Pay) is a product that provides electronic delivery of payments and remittance advices (EOBs and/or ERAs) to physicians, hospitals and other health care professionals.
  • ERA: Electronic remittance advice (ERA) is also known as the HIPAA 835.
  • HIPAA 835: The 835 transaction is a standard transaction mandated by the Health Insurance Portability and Accountability Act (HIPAA) and is used to transfer payment and remittance information for adjudicated professional and institutional health care claims. The 835 returns payment information that is reported on paper EOB/PRAs to the care provider (or clearinghouse), in an electronic format. The ERA/835 uses claim adjustment reason codes mandated by HIPAA. The EOB/PRA displays UnitedHealthcare proprietary denial/adjustment codes used in claim adjudication.

Use the Health Care Claim (837D) transaction to electronically submit dental claims. UnitedHealthcare accepts claims from both participating and non-participating care providers.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Accomplishes more with less — fewer phone calls, faxes or keying

Getting started


Please contact your software vendor or clearinghouse. If available, claim submission transactions may be integrated into your practice management system or hospital information system, or submitted through Direct Data Entry (DDE) or the UnitedHealthcare Provider Portal.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time solutions.

Use the Health Care Claim (837I) transaction to electronically submit institutional (hospital or facility) claims. UnitedHealthcare accepts claims from both participating and non-participating care providers.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Accomplishes more with less — fewer phone calls, faxes or keying

Getting started


Please contact your software vendor or clearinghouse. If available, claim submission transactions may be integrated into your practice management system or hospital information system, or submitted through Direct Data Entry (DDE) or the UnitedHealthcare Provider Portal.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time solutions.

Use the Health Care Claim (837P) transaction to electronically submit professional (physician) and vision claims. UnitedHealthcare accepts claims from both participating and non-participating care providers.

Benefits

  • Streamlines administrative tasks and increase productivity
  • Reduces administrative costs through automation
  • Increases data accuracy by reducing manual errors
  • Accomplishes more with less — fewer phone calls, faxes or keying

Getting started


Please contact your software vendor or clearinghouse. If available, claim submission transactions may be integrated into your practice management system or hospital information system, or submitted through Direct Data Entry (DDE) or the UnitedHealthcare Provider Portal.

Many vendors and clearinghouses also offer multi-payer, web-based batch or real-time solutions.