The short answer
A Healthcare EDI API lets your systems submit 837 claims and receive 835 remittance advice as JSON over REST — with 270/271 eligibility checks and delivery acknowledgements included. Your billing software never assembles X12 segments; the API layer translates between clean JSON and payer-compliant X12 at the boundary, under an executed BAA for production PHI.
837 claims out: JSON in, compliant X12 out
Send a claim as JSON — patient, provider, diagnoses, procedures, charges — and the platform validates it against payer companion-guide rules before it becomes X12. That pre-submission check catches the missing NPI, taxonomy, and qualifier errors that drive clearinghouse rejections.
{
"claim": {
"type": "837P",
"submitter": "demo-clearinghouse-id",
"patient": { "memberId": "W123456789" },
"diagnoses": ["J06.9"],
"serviceLines": [{ "cpt": "99213", "charge": 175.0 }]
}
}
The response carries validation results plus routing status — accepted, rejected with reasons, or pending payer acknowledgement (999/277CA). For claim-type detail, read the EDI 837 healthcare claims guide.
835 remittance back: X12 in, JSON out
Payer 835 files arrive as dense X12. The API parses them into structured JSON your billing system can auto-post: CLP segments become claim-level payment records, CAS adjustments carry CARC/RARC denial codes in plain fields, and PLB adjustments reconcile at the provider level. EFT payments reassociate through the TRN trace number.
Pair this with the EDI 835 remittance guide for a segment-by-segment walkthrough of CLP, CAS, SVC, and PLB.
270/271 eligibility without the phone queue
Eligibility checks follow the same pattern: send a 270 inquiry as JSON with member and service-type details, receive the 271 response with coverage, copay, and deductible fields your front desk can read. Fewer rejected claims starts with verified coverage before the visit is billed.
The BAA path for production PHI
Healthcare EDI API use stays HIPAA-aligned through the same controls as the rest of the platform: encryption in transit, least-privilege access, and audit logging. Healthcare X12 is included on every plan — map, validate, and test with synthetic or de-identified data first, then run production PHI on Growth or Enterprise with the published HIPAA/BAA add-on (included on Enterprise) under an executed BAA. Confirm current add-on terms on the EDI pricing page.
When a Healthcare EDI API fits — and when it does not
It fits when your billing software speaks JSON and a payer or clearinghouse requires X12: small practices, billing services, and digital-health teams that want claim submission and remittance posting without an X12 team. It does not replace payer enrollment, EFT/ERA registration, or payer certification calendars — those still run on the payer side while the API handles the document work your team controls.
For the broader EDI-versus-API decision, see EDI vs API. For the full transaction-set map, start with the X12 EDI guide.