Interpret claim status

Claim status codes tell you where a claim is in its lifecycle, such as accepted, rejected, pending, or finalized as paid or denied. Each status contains up to three codes:

Code type	What it tells you	Example
Claim Status Category Code	The broad state of a submission, claim, or service line.	A7 (Rejected for Invalid Information)
Claim Status Code	A more specific state. For rejections and denials, it typically gives the reason.	562 (Entity's National Provider Identifier (NPI))
Entity Identifier Code	The person, organization, or location related to the status. Not every status includes one.	85 (Billing Provider)

This page explains where to find the codes in 277CA claim acknowledgments and claim status check results, how they differ from the statuses in the Stedi portal, and how to interpret the codes you're most likely to receive.

Find claim status codes

The codes on this page come from X12, the standard that HIPAA requires for healthcare transactions. Payers and Stedi send these codes in 277CA claim acknowledgments and real-time claim status checks. The codes explain the details of a claim's status, including why Stedi or the payer rejected it. They can also pinpoint problems with specific parts of the claim, such as a service line or the billing provider's information.

Stedi also assigns each claim its own processing status, such as Rejected or Processed, in the Stedi portal's claims view. These Stedi statuses are different from the X12 codes on this page. They summarize where the claim is in its lifecycle, based on the 277CAs for the claim's latest submission and its 835 ERAs.

To learn what each of Stedi's claim processing statuses means, visit Claim processing status in the claims view documentation. When you review 277CAs or claim status checks directly, use the codes and guidance on this page.

277CA claim acknowledgments

Stedi and payers send 277CA claim acknowledgments after you submit a claim to tell you whether they accepted or rejected it for processing. These statuses don't indicate whether the payer approves or denies the claim.

To review a 277CA's statuses:

1. Go to the claims view and click the claim to open its timeline.
2. Click an Acknowledgment (277CA) to open its details page.
3. Review the statuses on the Overview tab. If the 277CA references more than one claim, use the claim menu, such as Claim 1 of 2, to switch between them.

Each status appears in its own section, with the Status category code, the Status code, and, when present, the Entity code. The section title shows which part of the submission the status covers, and it changes with the category code. Not every 277CA includes every section.

Check every section. A rejection in any section means Stedi or the payer rejected the claim. For example, when Stedi rejects a claim because of a problem with the billing provider's information, the rejection is in the Service provider issue section.

Section title	What it tells you
Billing provider	The status of the entire submission, not of a specific claim. It can show that Stedi or the payer accepted the submission even when the claim-level status shows a rejection. The section name changes depending on the status: Billing provider info: Stedi or the payer received the submission. Billing provider: The payer accepted the submission. This doesn't mean the payer accepted each claim in it, so check the Claim section for each claim's status. Billing provider issue: There's a problem with the submission.
Service provider	The status of all the claims for one billing provider. Stedi only includes this status when it rejects a claim because of a problem with the billing provider's information. Payers may include it for each billing provider in the submission. The section name changes depending on the status: Service provider info: The payer received the billing provider's claims. Service provider: The payer accepted the billing provider's claims. Service provider issue: There's a problem with the billing provider's information. This is the only version that appears in Stedi's 277CAs. This section is separate from the Service provider details section lower on the page, which lists the provider's name and NPI.
Claim	Whether Stedi or the payer accepted or rejected the claim, and why. The section name changes depending on the status: Claim info: Stedi or the payer received the claim, but the payer hasn't accepted it for adjudication yet. Claim: The payer accepted the claim for adjudication. Claim issue: Stedi or the payer rejected the claim. A rejection includes codes for each problem and can include an explanatory Message.
Service line	The status of a specific service line. Stedi only includes service line statuses when it rejects a claim because of a problem with service line information. Payers may include them in other cases. The section name changes depending on the status: Service line info: Stedi or the payer received the service line. Service line: The payer accepted the service line. Service line issue: Stedi or the payer rejected the claim because of a problem with this service line. Each section can include a Message and the service line's Line item control number. The Service lines table at the bottom of the Overview tab also lists these statuses.

Real-time claim status checks

A real-time claim status check returns the payer's current status for a claim that's in adjudication or has been adjudicated. If the results include more than one claim, use the claim menu, such as Claim 1 of 2, to switch between them.

The results page shows statuses in the following places:

• Claim status: The claim-level status, which applies to the entire claim. It lists the Status category code, the Status code, and, when the payer sends one, the Entity code.
• Service details: The status of each service line. The table lists the Status category code and Status code for each line. Hold the pointer over a code to display its description. The table doesn't show entity identifier codes for service lines.

For example, when the payer can't find the patient in their system, the claim-level status contains category code D0 (Data Search Unsuccessful) and status code 97 (Patient eligibility not found with entity). This can happen when the patient's demographic details are incorrect, such as a misspelled name, or when the provider submitted the claim to a different payer than the one the patient identified when receiving services. To resolve this and other checks that don't return a match, follow the claim status troubleshooting steps.

Common codes and next steps

The following sections explain how to handle the codes you're most likely to receive:

• Category codes: Which codes mean the claim moved forward, which mean the payer needs more information, and which signal a problem.
• Status codes: What each code means and the next steps to take.
• Entity identifier codes: The person, organization, or location related to the status.

Each section links to the full code list.

Category codes

The category code tells you the broad state of a submission, claim, or service line. For the full list, visit Claim Status Category Codes in the X12 documentation.

Prefixes

Every category code starts with a prefix of one or more letters, such as the A in A7 or the DR in DR01. The prefix indicates the high-level state.

277CAs typically contain only A category codes. Claim status responses typically contain other prefixes, including P and F codes for pending and finalized claims, D codes when the payer can't find a matching claim, and E codes when the payer can't process the request.

Codes with the same prefix can mean different things, so check the full category code. Category codes can have one of the following prefixes:

Prefix	Family	Meaning
A	Acknowledgment	Stedi or the payer received the claim and processed it to some stage. A0–A2 and A5 mean the claim moves forward. The other A codes signal a problem.
P	Pending	The claim is in adjudication, or it's on hold because the payer requested more information.
F	Finalized	Adjudication is complete, usually with a payment or a denial.
R	Request for additional information	The payer needs more information from you.
DR	Data reporting acknowledgment	The payer acknowledged a data reporting submission.
E	Error	Stedi or the payer couldn't process the request.
D	Data	The payer couldn't find a claim that matches the submitted data.

Claim moved forward

Category code	Meaning
A0–A2, A5	Stedi or the payer acknowledged the claim, and it moves forward.
P0–P2, P5	The claim is in adjudication.
F0–F4	Adjudication is complete, usually with a payment or a denial.

Payer needs more information

Category code	Meaning
P3	The payer is waiting for information that it already requested from the provider. The status code identifies the requested information.
P4	The payer is waiting for information that it already requested from the patient. The status code identifies the requested information.

Problem with the claim or request

Category code	Meaning
A3	Stedi or the payer returned the claim as unprocessable. The claim doesn't move forward.
A4	The payer has no matching claim. Typically returned for claim status checks.
A6	Stedi or the payer rejected the claim for missing information.
A7	Stedi or the payer rejected the claim for invalid information.
A8	Stedi or the payer rejected the claim because fields in the claim conflict with each other.
D0	The payer couldn't match a claim to the claim status check.
E0–E4	Stedi or the payer couldn't process the request. Typically returned for claim status checks. E1 and E2 typically mean the payer's system is unavailable. E0, E3, and E4 typically mean there's a problem with the information you sent.

Status codes

The following table lists common status codes and their next steps, in numerical order. Most indicate a problem, but some also appear on accepted or finalized claims. Many status codes name a field or entity, so combine them with the category code and entity identifier code to identify the problem.

For the full list, visit Claim Status Codes in the X12 documentation.

Status code	Meaning	What to do
0	Cannot provide further status electronically.	The payer won't return more detail electronically. Check the Electronic Remittance Advice (ERA), Explanation of Benefits (EOB), or Explanation of Payment (EOP) if you have one. Otherwise, contact the payer.
21	Missing or invalid information.	Look for a second status code that identifies the missing or invalid field. Correct the claim and resubmit.
25	Entity not approved.	The payer hasn't approved the entity, typically the billing provider. Check the provider's credentialing and enrollment status with the payer.
26	Entity not found.	The entity, typically the billing provider, isn't on file with the payer. Check the provider's NPI, Tax Identification Number (TIN), or other identifiers with the payer.
31	Subscriber and policyholder name mismatched.	The subscriber's name doesn't match the payer's records. Run an eligibility check to see the name the payer has on file, then resubmit with that name.
33	Subscriber and subscriber ID not found.	The subscriber's information and member ID don't match. Run an eligibility check to see the information the payer has on file, then resubmit with that information.
35	Claim/encounter not found.	The payer couldn't find a claim that matches the claim status check. Follow the claim status troubleshooting steps.
88	Entity not eligible for benefits for submitted dates of service.	The entity wasn't eligible on the dates of service. Run an eligibility check to confirm coverage on those dates.
96	No agreement with entity.	The entity, typically the billing provider, doesn't have an agreement with the payer. Check the provider's status with the payer.
97	Patient eligibility not found with entity.	The payer doesn't list the patient as eligible. Run an eligibility check to confirm coverage. For claim status checks, verify the patient demographics in the request.
109	Entity not eligible.	The entity, typically the patient, isn't listed as eligible with the payer. Run an eligibility check to confirm coverage.
116	Claim submitted to incorrect payer.	For claim status checks, check the provider's credentialing for claim status checks with the payer. Otherwise, confirm the patient's payer with an eligibility check.
125	Entity's name.	The entity's name is missing or doesn't match the payer's records. If the entity is the patient, run an eligibility check to see the name the payer has on file. Then correct and resubmit.
158	Entity's date of birth.	The entity's date of birth, typically the patient's, is missing or doesn't match the payer's records. If the entity is the patient, run an eligibility check to see the date of birth the payer has on file. Then correct and resubmit.
187	Date(s) of service.	The dates of service are missing or invalid. Check the dates and resubmit.
454	Procedure code for services rendered.	A procedure code is missing or invalid. Check the procedure codes and resubmit.
484	Business application currently not available.	Typically returned for claim status checks. Stedi returns this code when the payer limits the request rate. A payer can also return it when its system is temporarily unavailable. In all cases, retry later.
485	More information available than can be returned in real-time mode. Narrow your current search criteria.	Too many claims matched the claim status check. Add fields such as the submitted amount, Payer Claim Control Number (PCCN), and TIN, then resubmit.
494	Real-time requests not supported by the information holder, resubmit as batch request.	The payer doesn't support real-time claim status checks. Don't retry. Confirm the payer's support for claim status checks in the Payer Network.
505	Entity's first name.	The entity's first name is missing or doesn't match the payer's records. If the entity is the patient, run an eligibility check to see the name the payer has on file. Then correct and resubmit.
562	Entity's National Provider Identifier (NPI).	The NPI for the entity, typically the billing or rendering provider, is missing or doesn't match the payer's records. For claim status checks, Stedi also returns this code when the NPI in the request isn't a valid NPI. Check the NPI and resubmit. For claim status checks, check the billing provider NPI.
667	Real-time requests not supported by the information holder, do not resubmit.	Don't retry. Payers return this code when they don't support real-time claim status checks, and Stedi returns it when it can't route the request to the payer. Confirm the payer's support for claim status checks in the Payer Network.
689	Entity was unable to respond within the expected time frame.	The payer timed out. Typically returned for claim status checks. Retry the check.

Entity identifier codes

The entity identifier code identifies the person, organization, or location related to the status. For example, when category code A7 and status code 562 come with entity identifier code 85, the NPI problem is with the billing provider.

Code	Entity
1P	Provider
77	Service location
82	Rendering provider
85	Billing provider
DN	Referring provider
IL	Insured or subscriber
PR	Payer
QC	Patient

Determine next steps

Use the category code, status code, and entity identifier code together to understand a claim's status. For example, category code A7, status code 562, and entity identifier code 85 together mean a rejection for a problem with the billing provider's NPI.

The same status code can appear under different category codes, so we recommend checking the category code and status code together. For example, status code 21 (Missing or invalid information) can come with category code A6 (Rejected for Missing Information) or A7 (Rejected for Invalid Information).

Start with the category code to determine the claim's status, then use the status code and entity identifier code to decide on next steps.

Claim status	Category codes	Next steps
Acknowledged	A0–A2, A5	The claim moves forward. Wait for the payer's next 277CA or check its status later.
Pending	P0–P2, P5	The claim is in adjudication. Check again later.
Waiting for information	P3, P4	Use the status code to identify the information the payer requested.
Finalized	F0–F4	Adjudication is complete, usually with a payment or a denial. Stop checking. The payer typically sends an 835 ERA or EOB that explains the result.
Request for additional information	R codes	Send the payer the requested documentation.
Error	E0–E4	For E1 and E2, retry. For E0, E3, and E4, correct the request before resending. Some payers send E1 when the request is incorrect, so check the request if retries keep failing.
Rejected	A3, A6, A7, A8	Use the status code and entity identifier code to find the field to correct, then correct the claim and resubmit it.
Not found	A4, D0	The payer couldn't match a claim to the claim status check. Follow the claim status troubleshooting steps.