HIPAA 5010 EDI Transactions

The most common HIPAA transaction. Submitted by healthcare providers to payers (insurance companies) to request payment for services rendered. Contains patient demographics, diagnosis codes, procedure codes, and billing amounts.

Sent by payers back to providers after processing a claim. Details which services were paid, denied, or adjusted, along with payment amounts and reason codes. The electronic equivalent of an Explanation of Benefits (EOB).

Sent by providers to payers to verify a patient's insurance coverage before delivering services. Includes subscriber information and the specific benefits being queried.

The payer's response to a 270 inquiry. Contains detailed benefit information including coverage status, copay amounts, deductible balances, and plan limitations.

Sent by providers to payers to check the status of a previously submitted claim. Used to track claims through the adjudication process without phone calls.

The payer's response to a 276 inquiry. Reports the current status of the claim — whether it's received, pending, paid, denied, or requires additional information.

Used for prior authorization and referral requests. Providers submit these to payers to get approval before performing certain procedures or referring patients to specialists.

Used by employers and other entities to remit health insurance premium payments to payers. Contains payment details, subscriber identification, and coverage period information.

Used to enroll members in health plans and maintain their enrollment records. Employers send these to insurance companies when employees are added, removed, or have changes to their coverage.