Overview
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.
Payers sometimes require additional documentation to process claims, such as medical records, treatment plans, radiographs, photographs, itemized bills, and letters from providers. These documents are submitted as claim attachments.
You can submit claims and claim attachments through Stedi APIs, SFTP, and the Stedi portal.
API claim submission
You can submit claims and attachments to Stedi APIs in either JSON or X12 EDI format. We recommend this approach when you want to submit claims and attachments programmatically without dealing with the complexities of the X12 EDI format.
Stedi supports sending the following transactions to payers:
- 837P professional claim | JSON API | X12 EDI API
- 837I institutional claim | JSON API | X12 EDI API
- 837D dental claim | JSON API | X12 EDI API
- 275 attachments | JSON API | X12 EDI API
Stedi translates JSON requests into X12 EDI and validates the data using our growing library of claim edits to ensure claims comply with HIPAA and the payer's specifications.
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.
You can either poll or listen for event-driven webhooks to discover new 277CA claim acknowledgments and 835 Electronic Remittance Advice (ERAs). Then, you can use Stedi APIs to retrieve these responses in JSON format.
Learn more about API submission for professional, institutional, dental, and workers' compensation claims, as well as unsolicited claim attachments.
SFTP claim submission
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.
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.
Connect to Stedi’s server and drop compliant X12 EDI professional,
institutional, or dental claim files, as well as unsolicited 275
attachments, into the to-stedi directory.
Stedi automatically validates claims using our growing library of claim edits to ensure they comply with HIPAA and the payer's specifications. Then, Stedi routes claims to the test or production clearinghouse.
Stedi places claim responses - 277CA 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 and attachment submission.
X12 HIPAA format
The Health Insurance Portability and Accountability Act (HIPAA) mandates that claims and claim attachments 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 attachments 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.
Billing for 837 claims and 275 attachments
Transactions are billable at the usage rates specified in your contract, except for API calls that return 4xx or 5xx errors. For example, you won't be charged when a request fails because the payer isn't supported - in this case, Stedi returns a 400 HTTP status code.