A claim is a request for payment submitted to an insurance company or health plan. It details the medical services rendered to a patient, including information about the diagnosis, treatment, and any procedures performed. The claim is used to determine the reimbursement amount that the submitter (typically a medical provider) should receive from the insurance company.

You can programmatically submit claims and claim status requests through Stedi’s APIs. You can also submit claims through Stedi’s fully-managed SFTP server.

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API claims processing

You can submit most claim types and real-time claim status requests to Stedi’s APIs in either JSON or X12 EDI format. We recommend this approach when you want to submit claims and claim status requests programmatically without dealing with the complexities of the X12 EDI format.

1

Submit claims and claim status requests to Stedi.

Stedi supports sending the following transactions to payers:

Stedi automatically translates JSON requests into X12 EDI and validates requests to ensure they comply with HIPAA and the payer’s specifications.

2

Stedi delivers requests to the payer.

Stedi routes requests to the payer. Stedi receives payer responses in X12 EDI and transforms them into JSON to make them easier to ingest into your business systems.

3

Receive payer responses from Stedi.

  • Stedi returns synchronous claim status responses from the payer in real time.
  • You can either poll or listen for event-driven webhooks to discover new Claim Acknowledgment (277) and Electronic Remittance Advice (835) responses. Then, you can use Stedi’s APIs to retrieve these responses in JSON format.

Learn more about API submission for professional, institutional, and dental claims.

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SFTP claims processing

We recommend Stedi SFTP when you have an existing system that generates X12 EDI files, and you want to send them through Stedi without completing an API integration.

1

Create SFTP users.

You can create both test and production SFTP users. Test users can only send claims to Stedi’s test clearinghouse, which helps ensure you never accidentally send test claims to payers while you’re getting up and running.

2

Drop claims onto Stedi's SFTP server.

Connect to Stedi’s server and drop compliant X12 EDI professional, institutional, or dental claim files into the to-stedi directory.

3

Stedi processes the claim.

Stedi automatically validates the claim data and routes your claims to the test or production clearinghouse.

4

Retrieve claim responses from the SFTP server.

Stedi places claim responses - 277 Claim Acknowledgments and 835 ERAs - into the from-stedi directory in X12 EDI format. You can retrieve these responses from the directory at your preferred cadence.

Learn more about SFTP claim submission.

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X12 HIPAA format

The Health Insurance Portability and Accountability Act (HIPAA) mandates that claims and claim status requests be submitted in a standardized format: X12 HIPAA. X12 HIPAA is a type of Electronic Data Interchange (EDI), a data format developed in the 1970s to allow businesses to exchange documents electronically.

While some healthcare institutions can submit claims and claim status requests directly in X12 HIPAA, many of today’s software applications are built to use more modern data formats like JSON. That’s why Stedi offers two types of APIs for claims processing: one that accepts JSON and automatically converts it to X12 HIPAA behind the scenes, and another that accepts X12 HIPAA directly.

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