X12 277 Data Reporting Acknowledgment (X364)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Information Status Notification Transaction Set (277) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a health care payer or authorized agent to notify a provider, recipient, or authorized agent regarding the status of a health care claim or encounter or to request additional information from the provider regarding a health care claim or encounter, health care services review, or transactions related to the provisions of health care. This transaction set is not intended to replace the Health Care Claim Payment/Advice Transaction Set (835) and therefore, will not be used for account payment posting. The notification may be at a summary or service line detail level. The notification may be solicited or unsolicited.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HN
- Health Care Information Status Notification (277)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X364
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 277
- Health Care Information Status Notification
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Submitter could begin sending transactions using the number 0001 in this element and increment from there. The number must be unique within a specific functional group (GS to GE) and interchange (ISA to IEA), but can be repeated in other groups and interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This field contains the same value as data element GS08. The value is 005010X364. Some translator products strip off the ISA and GS segments prior to application (ST - SE) processing. Providing the information from GS08 at this level will help ensure the appropriate application mapping is utilized at translation time.
- 005010X364
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0085
- Information Source, Information Receiver, Provider of Service, Patient
Code identifying purpose of transaction set
- 08
- Status
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- The inventory file number of the transmission assigned by the Information Source's system. This number operates as a transaction (batch) control number.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Source Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- ACV
- Information Source
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
Transmission Receipt Control Identifier
To uniquely identify a transaction to an application
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This is a unique trace number that identifies a specific transaction. This number is assigned by the Information Source.
Information Source Receipt Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- This is the receipt date of the 837 by the entity creating the 277 acknowledgment. This date may or may not be the same date as the Information Source Process Date.
Information Source Process Date
To specify any or all of a date, a time, or a time period
- The Information Source Process Date applies to the processing of the 837 claim transaction file through a processing system. This date may or may not be the same date as the Information Source Receipt Date.
Code specifying type of date or time, or both date and time
- 009
- Process
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- 40
- Receiver
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
Information Receiver Application Trace Identifier
To uniquely identify a transaction to an application
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This element contains the value submitted in the BHT03 data element from the 837.
Information Receiver Status Information
To report the status, required action, and paid information of a claim or service line
- This segment will be used to convey information about an entire unit of work (e.g., single transaction of claims). Information contained at this level will be summary details pertaining to the unit of work being acknowledged. Examples include, but are not limited to, accepted for processing, and trading partner not authorized to submit to the Information Source's system.
- See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 40
- Receiver
Use when identifying the receiver entity in Loop 1000B of the 837.
- 41
- Submitter
Use when identifying the submitter entity in Loop 1000A of the 837.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Code indicating type of action
- STC03 at this level is intended to convey the electronic transmission status of the ST - SE envelope. The terms "Accept" and "Reject" refer to the electronic transmission status of the 837 transaction not the processing status.
- U
- Reject
Required when the entire claim transaction (ST-SE) is rejected due to submitter level errors. No subordinate HL information is reported.
- WQ
- Accept
Required when code value "U" is not used. At least one subordinate HL loop must be reported.
Monetary amount
- STC04 is the amount of original submitted charges.
- This will be the sum of all CLM02 values (claim charge) for the claims being acknowledged. In most instances, this will be the sum of charges submitted from ST to SE of a single 837 transaction set.
In situations where the 837 transaction from the Information Receiver is separated (e.g., due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.
Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Total Accepted Quantity
To specify quantity information
- Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.
- The purpose of this segment is to report the total number of claims accepted by the Information Source. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
Total Rejected Quantity
To specify quantity information
- Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.
- The purpose of this segment is to report the total number of claims rejected for this Information Receiver (e.g., not accepted) by the Information Source.
Total Accepted Amount
To indicate the total monetary amount
- Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.
- The purpose of this segment is to report the total of the claim charge amount (Sum of Loop ID 2300 CLM02) of claims accepted by the Information Source. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
Total Rejected Amount
To indicate the total monetary amount
- Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.
- The purpose of this segment is to report the total of the claim charge amount (Sum of Loop ID 2300 CLM02) of claims rejected by the Information Source.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 19
- Provider of Service
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing/Service Provider Name
To supply the full name of an individual or organizational entity
- This segment contains information which can be found in Loop 2010AA of the 837 implementation guides.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Billing/Service Provider Trace Identifier
To uniquely identify a transaction to an application
- Because the TRN segment is syntactically required in order to use Loop 2200C, TRN02 can either be a sender assigned value or a default value of zero (0).
- Required when a secondary provider identifier needs to be reported in the Loop ID 2200C REF Billing/Service Provider Secondary Identifier segment, or to provide the status of a specific billing/service provider's group of claims in the Loop ID 2200C STC Billing/Service Provider Status Information. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Billing/Service Provider Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
- Required when needed to provide the status of a specific Billing/Service Provider's group of claims. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 85
- Billing Provider
Code indicating type of action
- U
- Reject
Use this code to indicate that the provider's group of claims has been rejected. If any portion of the provider's group of claims is accepted then the code "WQ" - Accept must be used.
- WQ
- Accept
Monetary amount
- STC04 is the amount of original submitted charges.
- Sum of the Billing/Service Provider claims within the 837 transaction being acknowledged.
Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Billing/Service Provider Secondary Identifier
To specify identifying information
- Required when no billing/service provider identifier is sent in NM109 of this loop
OR
when an identification number in addition to that provided in NM109 of this loop is necessary for the processor to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1J
- Facility ID Number
- G2
- Provider Commercial Number
- LU
- Location Number
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Total Accepted Quantity
To specify quantity information
- The purpose of this segment is to report the total number of claims accepted by the Information Source for the Billing/Service Provider. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
- Required when reporting status for a specific billing/service provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
Total Rejected Quantity
To specify quantity information
- The purpose of this segment is to report the total number of claims rejected by the Information Source for the Billing/Service Provider.
- Required when reporting status for a specific billing/service provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
Total Accepted Amount
To indicate the total monetary amount
- The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) accepted by the Information Source for the Billing/Service Provider in this acknowledgment. Accepted claims include those where Loop ID 2200D STC03 = WQ (Accept) and/or EZ (Exception Occurred).
- Required when reporting status for a specific billing/service provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
Total Rejected Amount
To indicate the total monetary amount
- The purpose of this segment is to report the total dollar amount of claims (sum of CLM02) rejected by the Information Source for the Billing/Service Provider in this acknowledgment.
- Required when reporting status for a specific billing/service provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- PT
- Patient
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Patient Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Use when the HIPAA Individual Patient Identifier is mandated for use.
- MI
- Member Identification Number
Code identifying a party or other code
- This is the patient identifier. This data element is the value from Loop 2010CA NM109 of the submitted claim. If there is no value is in the Loop 2010CA NM109, then use the value from the Loop 2010BA NM109 of the submitted claim.
Claim Status Tracking Number
To uniquely identify a transaction to an application
- This segment is the patient control number submitted in the CLM01 of the 837.
- This number must be returned exactly as submitted in the 837 up to the 20 character limit as defined in the 837 guide.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Claim Level Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 40
- Receiver
- 41
- Submitter
- 45
- Drop-off Location
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- 82
- Rendering Provider
- 85
- Billing Provider
- DK
- Ordering Physician
- DN
- Referring Provider
- DQ
- Supervising Physician
- IL
- Insured or Subscriber
- P3
- Primary Care Provider
- PR
- Payer
- PRP
- Primary Payer
- PW
- Pickup Address
- QB
- Purchase Service Provider
- QC
- Patient
- SEP
- Secondary Payer
- SJ
- Service Provider
- TTP
- Tertiary Payer
- ZD
- Party to Receive Reports
- ZZ
- Mutually Defined
Use when indicating the Entity is an Other Operating Physician.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Code indicating type of action
- EZ
- Exception Occurred
Use when the Health Care Claim Status Code(s) reported in this segment and/or a line level STC segment serves as a warning to the submitter an error has been detected, but is not significant enough to reject the claim.
- U
- Reject
Use when there is a claim level reject reason OR any of the Loop ID 2220D claim service lines have been assigned an STC03 Action Code of `U' (Reject). Claim splitting of accepted vs rejected lines is not supported in this implementation.
- WQ
- Accept
Monetary amount
- STC04 is the amount of original submitted charges.
- Zero is an acceptable amount.
- This is the Loop ID 2300 CLM02 Total Claim Charge Amount from the submitted 837.
Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Free-form message text
- STC12 allows additional free-form status information.
- When an Information Source deems there is a need to use the Free Form Message Text enabled by this element, the Information Source is expected to request a new Health Care Claim Status Category and/or Health Care Claim Status code(s) to enable codification of the message thereby eliminating the need to use this field for that given purpose.
Data Receiver Claim Control Number
To specify identifying information
- Required when the Data Receiving Entity of the 837 assigns a specific number to the claim for processing and the number is available at the time of this acknowledgment. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- F8
- Original Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Payer Claim Control Number
To specify identifying information
- Required when acknowledging a Post Adjudicated Claim Data Reporting (PACDR) 837 and Loop ID 2320 SBR06 = `6'. If not required by this implementation guide, do not send.
- This is the Other Payer Claim Control Number from Loop 2330B (REF*F8) when SBR06 = `6' in Loop 2320.
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
To specify identifying information
- This number must be returned as received in the 837.
- Required when the Claim Identifier Number For Transmission Intermediary was sent in the 837. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Level Service Date
To specify any or all of a date, a time, or a time period
- For Institutional and Data Reporting claims, this is the statement period submitted in Loop ID 2300 (DTP01 = 434).
For Professional claims this information is derived from the earliest service level dates in Loop ID 2400 (DTP01 = 472) to the latest service level date.
For Dental claims this is the service date submitted in Loop ID 2300 (DTP01 = 472). If there is no service date in Loop ID 2300 (DTP01=472), then this is:
the service date in Loop ID 2400 (DTP01=472),
OR
it is the treatment start in Loop ID ID 2400 (DTP01=196),
OR
the treatment end in Loop ID 2400 (DTP01=198),
OR
both the treatment start and treatment end dates in Loop ID 2400 listing the date range as from treatment start date to the treatment end date.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
To supply payment and control information to a provider for a particular service
- For Institutional claims, when both an NUBC revenue code and HCPCS or HIPPS code are reported, the HCPCS or HIPPS code is reported in SVC01-2 and the revenue code is reported in SVC04. When only a revenue code is used, it is reported in SVC01-2.
- Required when a Reject Action Code (Loop ID 2220D STC03 =
U') is being assigned to a service line. OR Required when an Exception Occurred Action Code (Loop ID 2220D STC03 =EZ') is being assigned to a service line.
If not required by this implementation guide, do not send.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
- WK
- Advanced Billing Concepts (ABC) Codes
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-2, then SVC04 is not used.
- Value submitted on the original claim.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- Zero is an acceptable amount.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Level Status Information
To report the status, required action, and paid information of a claim or service line
- See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Health Care Claim Status Category Code is limited to category codes beginning with `DR'.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 45
- Drop-off Location
- 72
- Operating Physician
- 77
- Service Location
- 82
- Rendering Provider
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- DQ
- Supervising Physician
- P3
- Primary Care Provider
- PW
- Pickup Address
- QB
- Purchase Service Provider
- ZZ
- Mutually Defined
Use when indicating the Entity is an Other Operating Physician.
Code indicating type of action
- EZ
- Exception Occurred
Use when the Health Care Claim Status Code(s) reported in this segment and/or a line level STC segment serves as a warning to the submitter an error has been detected, but is not significant enough to reject the claim.
- U
- Reject
Required when additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required when additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Free-form message text
- STC12 allows additional free-form status information.
- When an Information Source deems there is a need to use the Free Form Message Text enabled by this element, the Information Source is expected to request a new Health Care Claim Status Category and/or Health Care Claim Status code(s) to enable codification of the message thereby eliminating the need to use this field for that given purpose.
Line Item Control Number
To specify identifying information
- This is the Line Item Control Number exactly as submitted in the 837 transaction for the original claim in Loop ID 2400, REF02 (REF01 = 6R). If a Line Item Control Number is not submitted, this will be the line sequence number Loop ID 2400 LX01.
Code qualifying the Reference Identification
- 6R
- Provider Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
To specify identifying information
- Required when a Pharmacy Prescription Number was sent in the 837 at the Service Line. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
To specify any or all of a date, a time, or a time period
- Required when the Date of Service from the original submitted claim for a specific line item is present. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- Data value in SE02 must be identical to ST02.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1
BHT*0085*08*0000221*20190221*1025~
HL*1**20*1~
NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~
TRN*1*ABC12345~
DTP*050*D8*20190220~
DTP*009*D8*20190221~
HL*2*1*21*1~
NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~
TRN*2*206438976580901~
STC*DR02>20*20190221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~
HL*3*2*19*1~
NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~
HL*4*3*PT~
NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
TRN*2*PATIENT22222~
STC*DR02>20>PR*20190221*WQ*100~
REF*F8*IC847502~
REF*1K*220216359803X~
DTP*472*D8*20190214~
HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*DR06>21*20190221*U*65******DR06>255~
REF*F8*IC429783~
REF*1K*220216359954X~
DTP*472*D8*20190121~
HL*6*3*PT~
NM1*QC*1*JONES*LARRY****MI*4444444444~
TRN*2*JONES44444~
STC*DR03>26>77*20190221*U*100~
REF*F8*IC429805~
REF*1K*220216359964X~
DTP*472*D8*20190211~
HL*7*2*19*1~
NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~
TRN*1*0~
REF*LU*AB142~
QTY*QA*2~
AMT*YU*100.5~
HL*8*7*PT~
NM1*QC*1*JOHNSON*MARY****MI*5555555555~
TRN*2*JOHNSON55555~
STC*DR08>20>PR*20190221*EZ*50.5~
REF*F8*IC429888~
REF*1K*220216359806X~
DTP*472*D8*20190210~
SVC*HC>G9938*50.5*****1~
STC*DR08>475**EZ~
REF*6R*1~
DTP*472*D8*20190210~
HL*9*7*PT~
NM1*QC*1*MILLS*HARRIETT****MI*6666666666~
TRN*2*MILLS66666~
STC*DR02>20>PR*20190221*WQ*50~
REF*F8*IC429956~
REF*1K*220216359807X~
DTP*472*D8*20190205~
SE*63*0003~
Example 2
BHT*0085*08*123456789*20190201*0405~
HL*1**20*1~
NM1*ACV*2*STATE ENCOUNTER SYSTEM*****46*STATE01~
TRN*1*20201312005S00002XYZABC~
DTP*050*D8*20190131~
DTP*009*D8*20190201~
HL*2*1*21*0~
NM1*40*2*ABC PAYER*****46*S00002~
TRN*2*2020131052389~
STC*DR03>24>41*20190201*U*800~
QTY*AA*3~
AMT*YY*800~
SE*14*0002~
Stedi is a registered trademark of Stedi, Inc. All names, logos, and brands of third parties listed on this page are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.