Reference 0001

Claim Transaction Map

A compact map from revenue-cycle workflow events to HIPAA transactions and product states for EMR and healthcare SaaS claim workflows.

Print this as a one-page desk reference after completing Lesson 0001.

The Short Flow

Workflow Moment	Transaction / Artifact	Product State Implication
Before or around scheduling, registration, or check-in	`270/271` eligibility inquiry and response	Coverage evidence, patient responsibility estimate inputs, payer/member mismatch workqueue.
After encounter documentation and coding	`837` health care claim: professional, institutional, or dental	Claim draft becomes claim submitted. Product must track submitter, payer, batch, control numbers, and validation outcomes.
Immediately after submission	Acknowledgments, clearinghouse edits, payer front-end edits	Do not call this a denial. This is usually a rejection or acceptance workflow before adjudication.
While waiting for adjudication	`276/277` claim status request and response	Automated status polling, stale-claim queues, and operational follow-up.
After payer adjudication	`835` electronic remittance advice and possible EFT	Payment posting, contractual adjustments, patient responsibility, denial reason routing, and provider-level balance handling.

A claim or batch failed an intake or validation step before normal payer adjudication. Fix the data and resubmit.

A payer adjudicated the claim and did not pay all or part of it. Work it through denial management, appeal, correction, or write-off.

An amount on the remittance that explains the difference between billed charge, allowed amount, paid amount, and responsibility.

CMS Transactions Overview defines health care administrative transactions.
CMS Adopted Standards and Operating Rules maps transaction types to standards like 837, 270/271, 276/277, and 835.
CMS Electronic Health Care Claims explains front-end edits, implementation-guide edits, and coverage/payment edits.
CMS Health Care Payment and Remittance Advice explains ERA, 835, group codes, CARCs, RARCs, and payment posting details.