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.
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.
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 EDI 275 transaction to submit additional information related to a claim, instead of using mail or fax. Unsolicited attachments are those you send us that we didn’t request. They can be sent for claims that are likely to result in a request for additional information. Solicited attachments are those where we request additional information, when needed, to process a claim.
Two ways to send information
We want to make working with us easier, which includes the ability to submit all the information electronically.
In partnership with our affiliate, Optum, we’re working to add more clearinghouses that can accept unsolicited EDI 275 claim attachments. Currently, the clearinghouse Jopari has this capability.
If your organization is currently working with Jopari, please contact them directly to get started.
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.
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.
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.
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.
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.
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.
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.
Use the Health Care Claim (837D) transaction to electronically submit dental claims. UnitedHealthcare accepts claims from both participating and non-participating care providers.
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.
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.
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.