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Updated: Mar 4

"A transaction is an electronic exchange of information between two parties to carry out financial or administrative activities related to health care”.


•Health claims (institutional, professional, and dental)

•Eligibility and benefit verification

•Prior authorization and referrals

•Claim status inquiry and response

•Claim payment (or EFT, electronic funds transfer)

•Electronic remittance advice (ERA)

•Coordination of benefits

•Referral certification

•Retail pharmacy drug claim submission

•Medicaid pharmacy subrogation

•Enrollment/disenrollment in a health plan

•Premium payment/explanation (employer)


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