EDI 277 X228 - Health Care Information Status Notification

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.

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Heading

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

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

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

   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 Mandatory · Max 1

      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 Mandatory · Max 1

         To supply the full name of an individual or organizational entity

   3. 2000B Loop Mandatory Repeat 1

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

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

      2. 2100B Loop Mandatory Repeat 1

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

            To supply the full name of an individual or organizational entity

      3. 2000C Loop Mandatory Repeat >1

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

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

         2. 2100C Loop Mandatory Repeat 2

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

               To supply the full name of an individual or organizational entity

               This is the billing provider from the original submitted claim. This may also be the service provider from the original submitted claim. The provider identified facilitates identification of the claim within a payer's system.
               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. 2000D Loop Mandatory Repeat >1

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

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

            2. 2100D Loop Mandatory Repeat 1

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

                  To supply the full name of an individual or organizational entity

            3. 2200D Loop Mandatory Repeat >1

               1. 0900 · TRN · Payer Claim Control Number Mandatory · Max 1

                  To uniquely identify a transaction to an application

                  This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).

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

                  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 · Patient Control Number Optional · Max 1

                  To specify identifying information

                  The maximum number of characters supported for the Patient Control Number is `20'.

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

                  To specify identifying information

               5. 1100 · REF · Pharmacy Prescription Number Optional · Max 1

                  To specify identifying information

               6. 1100 · REF · Claim Identification Number For Clearinghouses and Other Transmission Intermediaries Optional · Max 1

                  To specify identifying information

                  Although this REF is supplied for transmission intermediaries to;attach their own unique claim number to a claim/encounter, recipients;are not required to return this number. Trading partners may voluntarily agree to this interaction if they wish.

               7. 1200 · DTP · Claim Service Date Optional · Max 1

                  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.

               8. 1200 · DTP · Claim Received Date Mandatory · Max 1

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

                  This is the date the claim was accepted into the payer's adjudication system for processing.

               9. 2220D Loop Optional Repeat >1

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

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

                     Only those service lines that caused the pended status are to be reported.
                     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 Mandatory · Max >1

                     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 Optional · Max 1

                     To specify identifying information

                     Only 1 REF Segment may be reported in the 2220 Loop.

                  4. 2000 · REF · Pharmacy Prescription Number Optional · Max 1

                     To specify identifying information

                     Only 1 REF Segment may be reported in the 2220 Loop.

                  5. 2100 · DTP · Service Line Date Mandatory · Max 1

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

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

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