Payer Integration Testing: A Go-Live Checklist for EDI Implementation Teams
A practical pre-go-live checklist for healthcare EDI payer integration — covering claim submission, remittance, eligibility, prior auth, and the envelope-level checks most teams miss.
Fig. 1 — Payer integration test coverage by category
This checklist covers the complete payer integration test matrix for a healthcare EDI go-live. Work through each section before you flip the ISA15 flag to P.
1. Trading partner and envelope verification
☐ ISA05/ISA06 sender qualifier and ID match payer TPA exactly (15-char padded)
☐ ISA07/ISA08 receiver qualifier and ID match payer TPA exactly
☐ ISA15 = T for test, P for production — verify before go-live
☐ GS02/GS03 application IDs match payer TPA (may differ from ISA IDs)
☐ GS08 version string correct for each transaction type
☐ TA1 interchange acknowledgment received and processed for test submission
☐ 999 functional acknowledgment received with AK1*HC*1 (accepted) for test claim
☐ Submission endpoint confirmed — sandbox vs production URL differ
2. 837 claim submission
☐ Simple 837P professional claim accepted and acknowledged
☐ 837I institutional claim accepted (if applicable)
☐ NM1*85 billing provider NPI matches payer provider enrollment
☐ NM1*82 rendering provider NPI matches payer provider enrollment
☐ CLM05 place of service code matches facility type
☐ HI diagnosis codes accepted (ICD-10-CM, correct qualifier ABK/ABF)
☐ SV1 procedure codes accepted (CPT/HCPCS with correct modifiers)
☐ COB claim with primary payer OI loop accepted
☐ Retro authorization claim (REF*9F with prior auth number) accepted
☐ Claim with multiple service lines accepted
3. 277 claim status
☐ 277CA claim acknowledgment received after 837 submission
☐ 277 status STC codes interpreted correctly by billing system
☐ A1 (accepted) and A2 (rejected) statuses both handled
☐ Payer-assigned claim number (REF*1K) captured for status inquiry
4. 835 remittance
☐ Full payment 835 received and auto-posted correctly
☐ CO-45 contractual adjustment written off automatically
☐ PR-1 patient deductible creates patient balance (not written off)
☐ PR-2 patient coinsurance creates patient balance
☐ Full denial (zero-pay CLP) suspends claim with correct reason code
☐ CLP with multiple SVC lines posts correctly at line level
☐ COB secondary 835 with OA-23 adjustment posts correctly
☐ PLB provider-level adjustment captured in AR system
☐ Reversal (CLP reason code 22) finds and reverses prior posting
5. 278 prior authorization
☐ 278 request submitted and TA1/999 acknowledgment received
☐ 278 response (approval) received and auth number stored
☐ 278 response (denial) handled and communicated to clinical team
☐ Auth number from 278 response flows to REF*9F in downstream 837
☐ Retro auth scenario (service date before auth date) accepted
6. Sign-off and evidence
☐ All test scenarios documented with pass/fail status
☐ Each scenario linked to the transaction evidence (actual EDI content)
☐ PDF sign-off report generated and reviewed by PMO
☐ Payer test coordinator has confirmed production readiness
☐ ISA15 flip to P scheduled and documented
☐ Rollback plan documented in case of production failures
Synthibase generates synthetic test data for every item on this checklist — 837, 835, 277, 278, COB scenarios, retro auth, and full denials — from a persistent patient registry configured to your payer mix. Every test run produces structured evidence you can export as a PDF sign-off report. Start a free trial →