New: Drop-in replacement for Change Healthcare APIs

EDI 277 X214 - Claim Acknowledgement

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 decision maker in the business transaction. For this business use, this entity is the payer or clearinghouse receiving the ASC X12 837 transaction.

   2. 2100A Loop Mandatory Repeat 1

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

         To supply the full name of an individual or organizational entity

   3. 2200A Loop Mandatory Repeat 1

      1. 0900 · TRN · Transmission Receipt Control Identifier · Max 1 · Mandatory

         To uniquely identify a transaction to an application

      2. 1200 · DTP · Information Source Receipt Date · Max 1 · Mandatory

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

      3. 1200 · DTP · Information Source Process Date · Max 1 · Mandatory

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

         Payers and clearinghouses often collect claim transmissions throughout the business day. A process which is usually called "batch" is initiated at least once per business day. Some entities may initiate this process more than one time per day. As claim transmission files are processed, EDI reports and or data files are generated from the entity's computer system(s) and are distributed to the Information Receiver.
         The Information Source Process Date applies to the processing of the 837 claim transaction file through a pre-adjudication/electronic data interchange (EDI) system. This date may or may not be the same date as the Information Source Receipt Date.

   4. 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

         The Information Receiver is the entity that expects the response from the Information Source. For this business use, this entity can be a provider, a provider group, a claims clearinghouse, a service bureau, an agency, an employer etc.

      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

            The Information Receiver identified in the NM1 is always the electronic connection to the Information Source EDI environment. The Information Receiver has a trading partner profile set up at the Information Source's site and is generally the entity that submitted the claim transaction(s) for processing.
            For situations where a person such as a single practitioner submits claim transactions to a payer, the entity identified in the Provider of Service Loop (HL03 = 19) will be the same entity identified here in the Information Receiver Loop (HL03 = 21). The difference may be that the trading partner profile set up in the EDI environment is a separate identification scheme from the identification number set up for the entity in the adjudication system.
            In the situation where there is more than one clearinghouse involved in the transmission of the Health Care Claim Acknowledgement as part of the Trading Partner Agreement, this segment will be used to identify the clearinghouse that is passing the information. This segment will be changed to display the information for the next clearinghouse before they continue passing on the transmission. This process will continue until the transmission reaches the initiator of the claim/encounter.

      3. 2200B Loop Mandatory Repeat 1

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

            To uniquely identify a transaction to an application

            This segment contains the value submitted in the BHT03 data element from the 837.

         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

            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, trading partner not authorized to submit to the Information Source's system, etc.
            See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

         3. 1210 · QTY · Total Accepted Quantity · Max 1 · Optional

            To specify quantity information

            The purpose of this segment is to report the total number of claims accepted by the Information Source.
            Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.

         4. 1210 · QTY · Total Rejected Quantity · Max 1 · Optional

            To specify quantity information

            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.
            Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.

         5. 1220 · AMT · Total Accepted Amount · Max 1 · Optional

            To indicate the total monetary amount

            The purpose of this segment is to report the total dollar amount of claims accepted by the Information Source.
            Required when at least one claim is accepted for this Information Receiver. If not required by this implementation guide, do not send.

         6. 1220 · AMT · Total Rejected Amount · Max 1 · Optional

            To indicate the total monetary amount

            The purpose of this segment is to report the total dollar amount of claims rejected for this Information Receiver (e.g. not accepted) by the Information Source.
            Required when at least one claim is rejected for this Information Receiver. If not required by this implementation guide, do not send.

      4. 2000C Loop Optional Repeat >1

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

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

            Required when STC03 at the Information Receiver Level (2200B) is equal to "WQ" (ACCEPTED). If not required by this implementation guide, do not send.
            This loop and all subsequent loops are not used when the Information Receiver STC03 is equal to "U" (REJECT).

         2. 2100C Loop Mandatory Repeat 1

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

               To supply the full name of an individual or organizational entity

               This segment contains information which can be found in the 837 Dental, Institutional, and Professional implementation guides at the 2010AA loop.

         3. 2200C Loop Optional Repeat 1

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

               To uniquely identify a transaction to an application

               Required when 2200C Loop is used to provide the status of a specific provider's group of claims in the STC segment or a secondary provider identifier needs to be reported in the Provider Secondary REF segment. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
               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).

            2. 1000 · STC · Billing Provider Status Information · Max >1 · Optional

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

               Required when needed to provide the status of a specific Billing 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.
               See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

            3. 1100 · REF · Provider Secondary Identifier · Max 3 · Optional

               To specify identifying information

               Required when an additional identification number to that provided in NM109 of this loop is necessary for the claim processor to identify the entity. If not required by this implementation guide, do not send.

            4. 1210 · QTY · Total Accepted Quantity · Max 1 · Optional

               To specify quantity information

               Required when reporting status for a specific provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
               The purpose of this segment is to report the total number of claims (sum of CLM02) accepted to the adjudication process by the Information Source for the Billing Provider in this acknowledgment.

            5. 1210 · QTY · Total Rejected Quantity · Max 1 · Optional

               To specify quantity information

               Required when reporting status for a specific provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
               The purpose of this segment is to report the total number of claims rejected by the Information Source for the Billing Provider.

            6. 1220 · AMT · Total Accepted Amount · Max 1 · Optional

               To indicate the total monetary amount

               Required when reporting status for a specific provider's group of claims and at least one claim is accepted. If not required by this implementation guide, do not send.
               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 Provider in this acknowledgment.

            7. 1220 · AMT · Total Rejected Amount · Max 1 · Optional

               To indicate the total monetary amount

               Required when reporting status for a specific provider's group of claims and at least one claim is rejected. If not required by this implementation guide, do not send.
               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 Provider in this acknowledgment.

         4. 2000D Loop Optional Repeat >1

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

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

               This HL level contains information about the Patient identified in the 837 transaction. See Section 1.4.1.1 - Defining the Patient Participant for information on identifying the Patient data from the 837 Transaction.
               Required when reporting claim status at the patient level. If not required by this guide, do not send.

            2. 2100D Loop Mandatory Repeat 1

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

                  To supply the full name of an individual or organizational entity

            3. 2200D Loop Mandatory Repeat >1

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

                  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.

               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 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

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

                  To specify identifying information

                  This number will be used to track the adjudication of the claim throughout the adjudication system.
                  Required when a payer 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.

               4. 1100 · REF · Claim Identifier For Transmission Intermediaries · Max 1 · Optional

                  To specify identifying information

                  Required when the Claim Identifier Number for Clearinghouse and Other Transmission Intermediary was sent in the 837. If not required by this implementation guide, do not send.
                  This number must be returned as received in the 837.

               5. 1100 · REF · Institutional Bill Type Identification · Max 1 · Optional

                  To specify identifying information

                  Required for Institutional claims when Institutional Type of Bill was received on the claim. If not required by this implementation guide, do not send.

               6. 1200 · DTP · Claim Level Service Date · Max 1 · Mandatory

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

                  For Institutional claims, it is the statement period in loop 2300 (DTP01 - 434). For Professional claims this information is derived from the earliest service level dates in loop 2400 (DTP01-472) to the latest service level date. For Dental claims it is the service date at the claim loop 2300 (DTP01=472).

               7. 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 a service line is being rejected and caused the rejection of a claim. If not required by this implementation guide, do not send.
                     Not used if the claim is being accepted into the adjudication system.
                     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.

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

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

                     See Section 1.4.2 - Status Information (STC) Segment Usage for specific STC segment information, composites and code use.

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

                     To specify identifying information

                     This is the line Item Control Number exactly as submitted on the original claim in Loop 2400, REF02 (REF01-6R). If a Line Item Control Number is not submitted, this will be the line sequence number (LX01) of the service line.

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

                     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.

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

                     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.

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)