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  • Life of A Medical Claim Submission Billing Payment.d14dcdaf66de

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    shubham vishwakarma
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    This document outlines the typical process and transactions involved in a medical insurance claim. It shows the exchanges between a provider of service, insurance provider, and insurance group or business. The provider submits a claim to the insurance provider using an 837 transaction, and can inquire about eligibility, claim status, or authorization using 270, 276, or 278 transactions respectively. The insurance provider responds with eligibility information via 271, claim acknowledgment or payment via 835 or 277, and other outbound transactions to complete the claim.

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    This document outlines the typical process and transactions involved in a medical insurance claim. It shows the exchanges between a provider of service, insurance provider, and insurance group or business. The provider submits a claim to the insurance provider using an 837 transaction, and can inquire about eligibility, claim status, or authorization using 270, 276, or 278 transactions respectively. The insurance provider responds with eligibility information via 271, claim acknowledgment or payment via 835 or 277, and other outbound transactions to complete the claim.

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    © All Rights Reserved
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    3 views1 page

    Life of A Medical Claim Submission Billing Payment.d14dcdaf66de

    Uploaded by

    shubham vishwakarma
    This document outlines the typical process and transactions involved in a medical insurance claim. It shows the exchanges between a provider of service, insurance provider, and insurance group or business. The provider submits a claim to the insurance provider using an 837 transaction, and can inquire about eligibility, claim status, or authorization using 270, 276, or 278 transactions respectively. The insurance provider responds with eligibility information via 271, claim acknowledgment or payment via 835 or 277, and other outbound transactions to complete the claim.

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    © All Rights Reserved
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    of 1

    Life of a Medical Claim

    Provider of Service Insurance Provider Insurance Group


    (Direct) or Business
    Inbound Transactions
    Outbound Transactions 837- Claims Submission Outbound Transactions
    837- Claim Submission 270- Eligibility Inquiry 834- Enrollment
    270- Eligibility Inquiry 276- Claim Status Inquiry 820- Premium Payment
    276- Claim Status Inquiry 278- Auth/Referral Request
    278- Auth/Referral Request 834- Enrollment Inbound Transactions
    820- Premium Payment 834- Enrollment
    Inbound Transactions 820- Premium Payment
    997- Functional Acknowledgement Outbound Transactions
    999- 5010 Acknowledgment 997- Functional Acknowledgement
    277- Claim Acknowledgment 999- 5010 Acknowledgment
    835- Remittence Advice 277- Claim Acknowledgment
    271- Eligibility Response 835- Remittence Advice
    271- Eligibility
    277- Claim Sattus Response
    834- Enrollment

    Provider of Service Third Party


    (Third Party) $ (Billing Agent or
    Clearing House)
    Outbound Transactions
    837- Claim Submission Outbound Transactions
    270- Eligibility Inquiry 837- Claim Submission
    276- Claim Status Inquiry 270- Eligibility Inquiry
    278- Auth/Referral Request 276- Claim Status Inquiry
    Proprietary File 278- Auth/Referral Request

    Inbound Transactions Inbound Transactions


    835- Remittence Advice 835- Remittence Advice
    271- Eligibility 271- Eligibility
    277- Claim Status Response 277- Claim Status Response
    278- Auth/Referral Request

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