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X12 transaction guide · Healthcare and insurance

EDI 274 Healthcare Provider Information

The X12 document used to exchange demographic and professional qualification information about healthcare providers.

Sent by
Provider, provider network or credentialing organization
Received by
Health plan, network or directory maintainer
Standard
ANSI ASC X12

What is an EDI 274?

The EDI 274 Healthcare Provider Information is the ANSI X12 transaction set used to exchange demographic and educational or professional qualification information about healthcare providers between providers, provider networks and any other entity that maintains or verifies healthcare provider information.

Health plans maintain provider directories and credential providers before they join networks. Accurate data on locations, specialties, licenses and whether providers accept new patients matters to members and regulators. Exchanging it in a standard format reduces the burden of repeated data requests on providers.

How the EDI 274 worksDiagram of the EDI 274 Healthcare Provider Information. Provider, provider network or credentialing organization sends it to health plan, network or directory maintainer. It usually starts the exchange. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level) and the required 2100 loop with NM1 (Individual or Organizational Name). 6 optional loops are listed by their first segment.How the EDI 274 worksHealthcare Provider Information: who sends it, where it fits and what the standard marks required1 WHERE IT FITSUSUALLY FOLLOWSStarts the exchangeEDI 274SENDERProvider, providernetwork orcredentialingorganizationRECEIVERHealth plan, networkor directory maintainer997 or 999 acknowledgment back, if the partners agreeUSUALLY FOLLOWED BY997FunctionalAcknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDsISA … IEAFunctional group, ID code PWGS … GETransaction set 274ST … SEHEADINGBHTBeginning of Hierarchical TransactionDETAILRequired loop 2000 · repeats many timesHLHierarchical LevelRequired loop 2100 · repeats many timesNM1Individual or Organizational Name+ 6 optional loops, starting with:NX1LQHPLREFEMSLXBlue box: required loop. Optional loops are listed by the segment that starts them; when a loop is used, that first segment is required. Optional segmentsoutside loops are not drawn.Structure: required segments and loops in the X12 008010 listing for the 274. Your trading partner's implementation guide adds its own requirements.
How the EDI 274 worksDiagram of the EDI 274 Healthcare Provider Information. Provider, provider network or credentialing organization sends it to health plan, network or directory maintainer. It usually starts the exchange. It is usually followed by 997. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level) and the required 2100 loop with NM1 (Individual or Organizational Name). 6 optional loops are listed by their first segment.How the EDI 274 worksHealthcare Provider Information: who sends it,where it fits and what the standard marksrequired1 WHERE IT FITSUSUALLY FOLLOWSStarts the exchangeEDI 274SENDERProvider,providernetwork orcredentialingorganizationRECEIVERHealth plan,network ordirectorymaintainer997 or 999 acknowledgment back, if the partnersagreeUSUALLY FOLLOWED BY997Functional Acknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDs (ISA… IEA)Functional group, ID code PW (GS … GE)Transaction set 274 (ST … SE)HEADINGBHTBeginning of HierarchicalTransactionDETAILRequired loop 2000 · repeatsmany timesHLHierarchical LevelRequired loop 2100 · repeatsmany timesNM1Individual orOrganizational Name+ 6 optional loops, starting with:NX1LQHPLREFEMSLXBlue box: required loop. Optional loops are listedby the segment that starts them; when a loop isused, that first segment is required. Optionalsegments outside loops are not drawn.Structure: required segments and loops in the X12008010 listing for the 274. Your trading partner'simplementation guide adds its own requirements.

How to read this diagram: the top row shows who sends the 274, to whom, and which documents usually come before and after it. The lower part shows what X12 release 008010 itself requires: the envelopes around the 274 and the segments and loops the standard marks as required, area by area. Optional loops are listed by the segment that starts them rather than drawn in full. This is the standard's minimum, not a trading partner's requirement: each partner's implementation guide usually makes some optional loops mandatory, restricts the codes and may use a different release.

Expand diagram Download SVG

When it is used

  • Updating provider directory information
  • Sharing credentialing data
  • Reporting changes in provider locations or specialties

Where it fits in the document flow

This document 274 Healthcare Provider Information
Usually followed by 997 Functional Acknowledgment

Structure

Mandatory segments in the 274 (X12 release 008010)

The segments X12 release 008010 marks as mandatory at their level, in order. Segments inside optional loops are needed only when the loop is used. This is the standard's requirement, not your trading partner's: each partner's implementation guide names the release it uses, adds the optional segments it requires and restricts the values. The requirement status comes from one published X12 reference listing and has not been checked against a second source.

  • ST
  • BHT
  • HL
  • NM1
  • NX1
  • LQ
  • HPL
  • REF
  • EMS
  • LX
  • SE

Practical example

The 274 in practice

A medical group adds two physicians and opens a new clinic. It sends its contracted health plans a 274 with the new providers' identifiers, specialties, licenses and the clinic's address and hours. The plans update their directories and start credentialing the new physicians.

Implementation

Implementation considerations for the 274

  • Use national provider identifiers where applicable.
  • Keep directory data current to meet regulatory requirements.
  • Validate licenses and credentials before activation.
  • Protect providers' personal information.

How ECOM helps

Automate the 274 with ECOM

Industry

Healthcare

Secure B2B integration and file transfer for providers, suppliers, distributors and healthcare partners.

Solution

Trading Partner Onboarding

EDI certification and automation onboarding for customers, suppliers and carriers, by whichever method each partner can support.

Solution

EDI Integration

Exchange X12 and EDIFACT documents with partners and integrate them directly with your ERP.

More general questions about EDI are answered in the EDI FAQ.

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