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.

​
Claims processing workflow

1

Submit claims and claim status requests to Stedi.

Stedi supports sending the following transactions to payers:

  • 837P (Professional) Health Care Claim
  • 837I (Institutional) Health Care Claim
  • 276 Claim Status Request

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.

​
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.

Was this page helpful?

Eligibility ManagerProfessional claims