Acknowledgments and ERAs overview

You can receive two types of transactions after you submit a professional, institutional, or dental claim through Stedi's APIs, an SFTP connection, or the Stedi portal:

• 277CA claim acknowledgments
• 835 Electronic Remittance Advice (ERA)

If you're submitting claims through SFTP, you'll also receive 999 Implementation Acknowledgments. Visit SFTP submission for details.

Claim response overview

Claim responses provide information about the status of a submitted claim as it moves through various stages of processing, validation, and adjudication. The following diagram illustrates the types of claim responses you may receive at each stage:

1

A provider submits a claim to Stedi (clearinghouse).

Stedi validates the claim according to industry standards and payer-specific rules (edits).

• If the claim fails validation, Stedi rejects it and doesn't send the claim to the payer. You'll need to correct the errors and resubmit.
• If the claim passes validation, Stedi accepts it and routes it to the payer. This doesn't indicate that the claim has been approved, only that the claim has passed Stedi's validation.

During this process, you may receive one or more 277CA claim acknowledgments from Stedi indicating the claim's acceptance or rejection status.

2

The payer receives the claim.

You'll receive additional 277CA claim acknowledgments from the payer letting you know that the claim has been received and whether it's been accepted or rejected for adjudication.

• If the payer rejects the claim, you'll need to correct the errors and resubmit. The payer can reject a claim before or after it enters their processing system.
• If the payer accepts the claim, they'll begin adjudication. This doesn't mean that the claim has been approved.

Once a claim has entered the payer's processing system, the 277CA usually contains the Payer Claim Control Number (PCCN) assigned to the claim in:

• transactions[].payers[].claimStatusTransactions[].claimStatusDetails[].patientClaimStatusDetails[].claims[].claimStatus.tradingPartnerClaimNumber
• Loop 2200D REF02, where REF01 = 1K (Payor's Claim Number)

3

The payer adjudicates the claim.

The payer may briefly pend the claim for additional review before making a final decision. This is common for high-dollar or complex claims which require manual review or supporting documentation (attachments).

Once the claim has been adjudicated, you'll receive an 835 Electronic Remittance Advice (ERA) from the payer with the adjudication details for each line item.

277CA claim acknowledgment

The 277CA indicates whether a claim was accepted for processing or rejected due to correctable errors, such as invalid data, missing information, or failure to comply with payer-specific rules.

A rejection is different from a denial. Claims are denied during adjudication, so you'll only see denial statuses in the 835 Electronic Remittance Advice (ERA). A 277CA rejection indicates that the claim never made it to the adjudication step. In these cases, the 277CA will include error codes and descriptions to help you correct the issues before resubmitting the claim.

You may receive multiple 277CAs for each claim you submit. You should monitor these 277CAs to track the claim's status as it moves through Stedi and the payer's systems:

• Clearinghouse: You'll receive the first 277CA from Stedi within about 30 minutes of submitting the claim to indicate whether we have accepted or rejected it. You may receive additional 277CAs as we route the claim to the payer.
• Payer: You'll receive one or more 277CAs from the payer. Typically, there is one 277CA that indicates receipt of the claim and a second 277CA that contains summary counts of transactions received, information about accepted transactions, and details for rejected transactions.

Each 277CA typically correlates to one 837 claim. However:

• Some payers may send a single 277CA that references multiple claims.
• Payers sometimes split a single claim into multiple claims during processing. In these cases, you may receive multiple 277CAs from the payer for the original claim you submitted.
• Payers may send another 277CA when they forward a claim to a secondary payer in a coordination of benefits scenario.

277CA vs. claim status check

The 277CA contains different information than a real-time claim status check. Specifically:

• 277CAs: Tell you whether the payer has received a claim and accepted it for processing. If the claim was rejected, 277CAs tell you why so you can resubmit. They don't indicate whether the claim has been adjudicated or paid.

• Real-time claim status checks: Tell you the status of a claim that's already been accepted into the payer's system. They provide information about whether the claim has been adjudicated, paid, denied, or is pending further review.

  That's why claim status checks can return more Claim Status Category Codes than a 277CA. Specifically, they can return codes in the P range for pending claims and codes in the F range for final claim statuses.

If you're waiting for an ERA, you should first check the related 277CA to confirm that the claim was accepted for processing. If the claim was rejected, you won't receive an ERA because the payer didn't adjudicate the claim.

Then, you can run a real-time claim status check to get updates about the claim's adjudication and payment status.

835 Electronic Remittance Advice (ERA)

Processing ERAs always requires transaction enrollment with the payer.

The ERA contains details about payments for specific services and explanations for any adjustments or denials. The payer only sends ERAs for claims they have accepted for adjudication. If a claim is rejected in a 277CA, there's no adjudication or payment information to report.

You'll typically only receive one 835 ERA per claim. However, payers may occasionally retransmit another identical duplicate ERA.