HIPAA X12 5010 claims, eligibility, remittance, and prior authorization — bridged with FHIR for the new payer-side APIs. Plus Canadian provincial billing and Infoway interoperability.
Every X12 5010 transaction set required for HIPAA-covered exchanges with payers, clearinghouses, and trading partners — in production with active connections today.
Verify coverage before the patient leaves the front desk; get prior auth decisions inside the same visit.
Professional, institutional, and dental claims — with structured acknowledgements so you know immediately what's accepted and what needs work.
Electronic remittance auto-posts to A/R; claim-status inquiries kill the phone call to the payer for "where's my claim?"
Six regulatory and standards shifts reshaping healthcare EDI roadmaps in 2026.
The CMS Interoperability and Prior Authorization Final Rule requires Medicare Advantage, Medicaid, CHIP, and QHP payers to expose FHIR-based PA APIs by January 1, 2027. Decisions must be returned in 72 hours (urgent) or 7 days (standard). X12 278 stays in play; FHIR PA APIs run alongside.
CMS finalized the HIPAA claims-attachment rule in January 2024 with a compliance date of January 1, 2027. X12 275 with LOINC-coded attachments becomes the standard for sending supporting documentation with claims and PAs — replacing fax and portal uploads.
CMS is preparing the NPRM for the next HIPAA version upgrade from X12 5010 to X12 7030. Final rule expected 2026; compliance dates likely 2028–2029. Adds support for ICD-11 readiness, more granular gender identity fields, and refined COB handling.
The Trusted Exchange Framework and Common Agreement (TEFCA) is now live with multiple designated QHINs. FHIR-based clinical exchange interoperates with X12 EDI flows — particularly for prior auth, eligibility, and care coordination across payer/provider boundaries.
CAQH CORE Phase V rules took effect for prior authorization, attachments, and care coordination in 2025 — raising the bar on response times, acknowledgement requirements, and data-content consistency across payers.
BC's MSP Teleplan and Alberta's WCB e-claims have modernized REST endpoints alongside legacy batch. Infoway's PrescribeIT continues nationwide rollout, and provinces are aligning on FHIR R4 for clinical data while keeping legacy HL7 v2 for hospital messaging.
Service Points runs the full revenue cycle against your EHR/EMR, your clearinghouse, and your payer network.
270 fires the moment the appointment is booked. 271 returns active coverage, deductible remaining, and copay — before the patient checks in.
Where a service needs PA, 278 (or FHIR PA API for CMS-0057 payers) fires automatically with the clinical context attached — not on the front desk's to-do list.
Coding and edit checks run before submission. The 837 leaves clean. The 277CA confirms receipt; rejections come back with the specific fix.
The ERA lands and posts automatically. Adjustments and patient responsibility split correctly. Denials route to the denial workflow with the CARC/RARC code already mapped to a corrective action.
Service Points healthcare EDI clients consistently report these gains within the first two months.
Book a 30-minute healthcare EDI assessment. Bring your top three payers and your messiest denial — we'll show you what the queue looks like when it cleans itself.