New: Drop-in replacement for Change Healthcare APIs

EDI 277 X212 - Status Request Response

Functional Group HN

X12N Insurance Subcommittee

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.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0200 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   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

Detail

1. 2000A Loop Mandatory Repeat >1

   1. 0100 · HL · Information Source Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

      This entity is the payer who has the current status information for the specified claims.

   2. 2100A Loop Mandatory Repeat 1

      1. 0500 · NM1 · Payer Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 0800 · PER · Payer Contact Information · Max 1 · Optional

         To identify a person or office to whom administrative communications should be directed

         Required when the payer's contact information is not otherwise specified in a Trading Partner Agreement and the Information Receiver does not know how to contact the payer. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
         When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. A telephone extension, when applicable is reported in the communication number immediately after the telephone number.

   3. 2000B Loop Mandatory Repeat >1

      1. 0100 · HL · Information Receiver Level · Max 1 · Mandatory

         To identify dependencies among and the content of hierarchically related groups of data segments

         This entity expects a response from the Information Source. See Section 1.4.1 Transaction Participants for more information on the Information Receiver.

      2. 2100B Loop Mandatory Repeat 1

         1. 0500 · NM1 · Information Receiver Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            This is the individual or organization requesting to receive the status information.;

      3. 2200B Loop Optional Repeat 1

         1. 0900 · TRN · Information Receiver Trace Identifier · Max 1 · Mandatory

            To uniquely identify a transaction to an application

            Required when rejecting claim status requests for errors at Information Source or Information Receiver levels. If not required by this implementation guide, do not send.
            If reporting error status at this level, 2000C, 2000D and 2000E Loops are not used.

         2. 1000 · STC · Information Receiver Status Information · Max >1 · Mandatory

            To report the status, required action, and paid information of a claim or service line

            See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

      4. 2000C Loop Optional Repeat >1

         1. 0100 · HL · Service Provider Level · Max 1 · Mandatory

            To identify dependencies among and the content of hierarchically related groups of data segments

            Required when status was not reported at the Information Receiver level. If not required by this implementation guide, do not send.
            This entity delivered the health care service. See Section 1.4.1 Transaction Participants for more information on the Provider.

         2. 2100C Loop Mandatory Repeat 2

            1. 0500 · NM1 · Provider Name · Max 1 · Mandatory

               To supply the full name of an individual or organizational entity

               During the transition to NPI, for those health care providers covered under the NPI mandate, two iterations of the 2100C Loop may be sent to accommodate reporting dual provider identification numbers (NPI and Legacy). When two iterations are reported, the NPI number will be in the iteration where the NM108 qualifier will be 'XX' and the legacy number will be in the iteration where the NM108 qualifier will be either 'SV' or 'FI'.
               After the transition to NPI, for those health care providers covered under the NPI mandate, only one iteration of the 2100C loop may be sent with the NPI reported in the NM109 and NM108=XX.

         3. 2200C Loop Optional Repeat 1

            1. 0900 · TRN · Provider of Service Trace Identifier · Max 1 · Mandatory

               To uniquely identify a transaction to an application

               Required when rejecting the claim status request(s) for errors at the provider level. If not required by this implementation guide, do not send.
               If reporting error status at this level, the 2000D and 2000E Loops related to this provider are not used.
               The TRN Segment is syntactically required in order to use the Loop 2200C STC. TRN02 can be either a default value of zero (0) or any value the Information Source chooses to assign.

            2. 1000 · STC · Provider Status Information · Max >1 · Mandatory

               To report the status, required action, and paid information of a claim or service line

               See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

         4. 2000D Loop Optional Repeat >1

            1. 0100 · HL · Subscriber Level · Max 1 · Mandatory

               To identify dependencies among and the content of hierarchically related groups of data segments

               When the patient is the subscriber or a dependent with a unique identification number, the claim status response information is reflected in the 2200D Loop under the Subscriber HL, 2000D Loop (HL03 = 22). The Dependent HL, 2000E Loop is not used. See Section 1.4.1.1 for more information on defining the patient.
               Required when the patient is the subscriber or a dependent with a unique identification number and status was not reported at the Provider level. If not required by this implementation guide, do not send.
               When requesting and responding to claim status for both a subscriber and a dependent of that subscriber, the Subscriber HL Loop 2000D must be followed by the subscriber's claim status data, Loop 2200D. In this instance, HL04=0 would be used. Then the Subscriber HL Loop 2000D must be repeated prior to the dependent HL Loop 2000E and their corresponding claim status data, Loop 2200E. In this instance, HL04=1 would be used. See Section 1.4.2.3 for an example of this structure.

            2. 2100D Loop Mandatory Repeat 1

               1. 0500 · NM1 · Subscriber Name · Max 1 · Mandatory

                  To supply the full name of an individual or organizational entity

            3. 2200D Loop Optional Repeat >1

               1. 0900 · TRN · Claim Status Tracking Number · Max 1 · Mandatory

                  To uniquely identify a transaction to an application

                  This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.
                  Required when the patient is the subscriber or a dependent with a unique identification number. If not required by this implementation guide, do not send.
                  When the patient is not the subscriber or a dependent with a unique identification number, the Loop 2200E TRN and subsequent segments will be used to reflect the claim status information.

               2. 1000 · STC · Claim Level Status Information · Max >1 · Mandatory

                  To report the status, required action, and paid information of a claim or service line

                  See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

               3. 1100 · REF · Payer Claim Control Number · Max 1 · Optional

                  To specify identifying information

                  Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
                  This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

               4. 1100 · REF · Institutional Bill Type Identification · Max 1 · Optional

                  To specify identifying information

                  Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

               5. 1100 · REF · Patient Control Number · Max 1 · Optional

                  To specify identifying information

                  Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
                  The maximum number of characters supported for the Patient Control Number is `20'.

               6. 1100 · REF · Pharmacy Prescription Number · Max 1 · Optional

                  To specify identifying information

                  Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.

               7. 1100 · REF · Voucher Identifier · Max 1 · Optional

                  To specify identifying information

                  Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
                  Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.

               8. 1100 · REF · Claim Identification Number For Clearinghouses and Other Transmission Intermediaries · Max 1 · Optional

                  To specify identifying information

                  Required when received on the 276 status request. If not required by this implementation guide, do not send.

               9. 1200 · DTP · Claim Service Date · Max 1 · Optional

                  To specify any or all of a date, a time, or a time period

                  For professional claims, this date is derived from the service level dates.
                  When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
                  Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

               10. 2220D Loop Optional Repeat >1

                   1. 1800 · SVC · Service Line Information · Max 1 · Mandatory

                      To supply payment and control information to a provider for a particular service

                      Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
                      For Institutional claims, when both an NUBC revenue code and a 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.

                   2. 1900 · STC · Service Line Status Information · Max >1 · Mandatory

                      To report the status, required action, and paid information of a claim or service line

                      See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

                   3. 2000 · REF · Service Line Item Identification · Max 1 · Optional

                      To specify identifying information

                      Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.

                   4. 2100 · DTP · Service Line Date · Max 1 · Mandatory

                      To specify any or all of a date, a time, or a time period

            4. 2000E Loop Optional Repeat >1

               1. 0100 · HL · Dependent Level · Max 1 · Mandatory

                  To identify dependencies among and the content of hierarchically related groups of data segments

                  When the patient is a dependent, the claim status response information is reflected in the 2200E Loop under the Dependent HL, 2000E Loop (HL03 = 23). See Section 1.4.1.1 for more information on defining the patient.
                  Required when the patient is a dependent who does not have a unique identification number. If not required by this implementation guide, do not send.

               2. 2100E Loop Mandatory Repeat 1

                  1. 0500 · NM1 · Dependent Name · Max 1 · Mandatory

                     To supply the full name of an individual or organizational entity

               3. 2200E Loop Mandatory Repeat >1

                  1. 0900 · TRN · Claim Status Tracking Number · Max 1 · Mandatory

                     To uniquely identify a transaction to an application

                     This is the trace or reference number from the originator of the transaction that was provided for this patient's 276 request.

                  2. 1000 · STC · Claim Level Status Information · Max >1 · Mandatory

                     To report the status, required action, and paid information of a claim or service line

                     See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

                  3. 1100 · REF · Payer Claim Control Number · Max 1 · Optional

                     To specify identifying information

                     Required when a claim is located in the Information Source's system. If not required by this implementation guide, do not send.
                     This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

                  4. 1100 · REF · Institutional Bill Type Identification · Max 1 · Optional

                     To specify identifying information

                     Required on institutional claims when different than the value submitted on the 276 request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                  5. 1100 · REF · Patient Control Number · Max 1 · Optional

                     To specify identifying information

                     Required when the Patient Control Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.
                     The maximum number of characters supported for the Patient Control Number is `20'.

                  6. 1100 · REF · Pharmacy Prescription Number · Max 1 · Optional

                     To specify identifying information

                     Required when the Pharmacy Prescription Number was submitted on the 276 request or when available on claims located in the Information Source's system. If not required by this implementation guide, do not send.

                  7. 1100 · REF · Voucher Identifier · Max 1 · Optional

                     To specify identifying information

                     Required when a voucher identifier is associated with the response claim. If not required by this implementation guide, do not send.
                     Some payers assign voucher identifiers to a group of claims as part of the payment process prior to payment being issued.

                  8. 1100 · REF · Claim Identification Number For Clearinghouses and Other Transmission Intermediaries · Max 1 · Optional

                     To specify identifying information

                     Required when received on the 276 status request. If not required by this implementation guide, do not send.

                  9. 1200 · DTP · Claim Service Date · Max 1 · Optional

                     To specify any or all of a date, a time, or a time period

                     For professional claims, this date is derived from the service level dates.
                     When reporting a claim level date, use the date from the Information Source's system for claim matches, otherwise return the date from the 276 status request.
                     Required for institutional claims or for professional and dental claims when the service line date is not used. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                  10. 2220E Loop Optional Repeat >1

                      1. 1800 · SVC · Service Line Information · Max 1 · Mandatory

                         To supply payment and control information to a provider for a particular service

                         Required when reporting status for Service Lines. If not required by this implementation guide, do not send.
                         For Institutional claims, when both an NUBC revenue code and a 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.

                      2. 1900 · STC · Service Line Status Information · Max >1 · Mandatory

                         To report the status, required action, and paid information of a claim or service line

                         See Section 1.4.3 - Status Information (STC) Segment Usage for specific STC segment information related to the hierarchical level, composites and code use.

                      3. 2000 · REF · Service Line Item Identification · Max 1 · Optional

                         To specify identifying information

                         Required when the Service Line Item Identification was submitted on the 276 request and service level status is reported. If not required by this implementation guide, do not send.

                      4. 2100 · DTP · Service Line Date · Max 1 · Mandatory

                         To specify any or all of a date, a time, or a time period

2. 2700 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)