Healthcare transactions and standards

The exchange of healthcare information can generally be viewed as a transaction between the sender and receiver participants.

Healthcare transactions include (but are not limited to):

• Healthcare claim or encounter
• Claim payment and remittance advice
• Healthcare claim status
• Coordination of benefits
• Eligibility for a health plan
• Referral certification and authorization
• Enrollment and un-enrollment in a health plan
• Premium payments
• Claim adjudication reporting

These transactions can be transmitted electronically in compliance with healthcare transaction standards.

Healthcare data exchange standards allow the accurate and timely exchange of information between healthcare organizations. For example, a simple benefits inquiry can take 20 minutes on the phone. By use of Electronic Data Interchange (EDI), this type of request can be processed almost immediately, without the need for a call to the customer service center.