X12 277 Claim Acknowledgement (X214)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HN
- Health Care Information Status Notification (277)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X214
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 277
- Health Care Information Status Notification
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Submitter could begin sending transactions using the number 0001 in this element and increment from there. The number must be unique within a specific functional group (GS to GE) and interchange (ISA to IEA), but can be repeated in other groups and interchanges.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This field contains the same value as data element GS08. The value is 005010X214. Some translator products strip off the ISA and GS segments prior to application (ST - SE) processing. Providing the information from GS08 at this level will help ensure the appropriate application mapping is utilized at translation time.
- 005010X214
Beginning of Hierarchical Transaction
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
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0085
- Information Source, Information Receiver, Provider of Service, Patient
Code identifying purpose of transaction set
- 08
- Status
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- The inventory file number of the transmission assigned by the Information Source's system. This number operates as a transaction (batch) control number.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Code specifying the type of transaction
- TH
- Receipt Acknowledgment Advice
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Source Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- AY
- Clearinghouse
Health care clearinghouse means a public or private entity that does either of the following:
(1) Processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction.
(2) Receives a standard transaction from another entity and processes or facilitates the processing of information into nonstandard format or nonstandard data content for a receiving entity. - PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
This number is used for entities identified in translation software typically called "Trading Partner Profiles". It is used for non-health plan entities.
- FI
- Federal Taxpayer's Identification Number
- PI
- Payor Identification
- XV
- Centers for Medicare and Medicaid Services PlanID
Code identifying a party or other code
Transmission Receipt Control Identifier
To uniquely identify a transaction to an application
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This is a unique trace number that identifies a specific transaction. This number is assigned by the Information Source.
Information Source Receipt Date
To specify any or all of a date, a time, or a time period
Code specifying type of date or time, or both date and time
- 050
- Received
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- This is the receipt date of the 837 by the entity creating the 277 acknowledgment. This date may or may not be the same date as the Information Source's Process Date.
Information Source Process Date
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.
Code specifying type of date or time, or both date and time
- 009
- Process
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
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.
Code identifying an organizational entity, a physical location, property or an individual
- 41
- Submitter
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 46
- Electronic Transmitter Identification Number (ETIN)
Code identifying a party or other code
Information Receiver Application Trace Identifier
To uniquely identify a transaction to an application
- This segment contains the value submitted in the BHT03 data element from the 837.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- This element contains the value submitted in the BHT03 data element from the 837.
Information Receiver Status Information
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.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Claim Status Category Code is limited to category types
A' for batch. For real time acknowledgements category typesA' andE' may be used except for E0. Use of the category typeE' is limited to indicating the business application system is unavailable. - CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 36
- Employer
- 40
- Receiver
- 41
- Submitter
- AY
- Clearinghouse
- PR
- Payer
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Code indicating type of action
- STC03 at this level is intended to convey the electronic transmission status of the ST - SE envelope. The terms "Accept" and "Reject" refer to the electronic transmission status of the 837 transaction not the billing status.
- U
- Reject
Required when the entire claim transaction (ST-SE) is rejected due to submitter level errors. No subordinate HL information is reported.
- WQ
- Accept
Required when code value "U" is not used. At least one subordinate HL loop must be reported.
Monetary amount
- STC04 is the amount of original submitted charges.
- This will be the sum of all CLM02 values (claim charge) for the claims being acknowledged. In most instances, this will be the sum of charges submitted from ST to SE of a single 837 transaction set.
In situations where the 837 transaction from the Information Receiver is separated (e.g. due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.
Required if additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required if additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Total Accepted Quantity
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.
Total Rejected Quantity
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.
Total Accepted Amount
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.
Total Rejected Amount
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.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 19
- Provider of Service
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Billing Provider Name
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.
Code identifying an organizational entity, a physical location, property or an individual
- 85
- Billing Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- FI
- Federal Taxpayer's Identification Number
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
The "XX" qualifier is required only when the National Provider ID is mandated for use.
After the National Provider ID implementation period, enumerated providers use only the NM108 and NM109 data elements and discontinue the generation of the REF segment in Loop ID 2200C.
Code identifying a party or other code
Provider of Service Information Trace Identifier
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).
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Billing Provider Status Information
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.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Claim Status Category Code is limited to category types
A' for batch. For real time acknowledgements category typesA' andE' may be used except for E0. Use of the category typeE' is limited to indicating the business application system is unavailable. - CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 36
- Employer
- 40
- Receiver
- 41
- Submitter
- 77
- Service Location
- 82
- Rendering Provider
- 85
- Billing Provider
- 87
- Pay-to Provider
- AY
- Clearinghouse
- PR
- Payer
Code indicating type of action
- STC03 at this level is intended to convey the electronic claim status of the Billing Provider Claims. The terms "Accept" and "Reject" refer to the status of claims for the Billing Provider not the billing status.
- U
- Reject
Use this code to indicate the provider's group of claims has been rejected. If any portion of the provider's group of claims is accepted then the code "WQ" - Accept must be used.
- WQ
- Accept
Monetary amount
- STC04 is the amount of original submitted charges.
- Sum of the Billing Provider claims within the 837 transaction being acknowledged.
- In situations where the 837 transaction from the Information Receiver is separated (e.g. due to clearinghouse involvement), this amount will be the sum of the CLM02 values for the claims being acknowledged.
Required if additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required if additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Provider Secondary Identifier
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.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- G2
- Provider Commercial Number
- LU
- Location Number
- SY
- Social Security Number
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Total Accepted Quantity
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.
Total Rejected Quantity
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.
Total Accepted Amount
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.
Total Rejected Amount
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.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- PT
- Patient
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Patient Name
To supply the full name of an individual or organizational entity
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
Required if the HIPAA Individual Patient Identifier is mandated for use. If not required use MI.
- MI
- Member Identification Number
Code identifying a party or other code
- This may be a unique identification number for the patient or it may be the subscriber's identification number. This data element is the value from the NM109 identifying the patient in the submitted claim.
When the payer does not use a unique member identification number for the patient, the subscriber identification number should be used.
Claim Status Tracking Number
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.
Code identifying which transaction is being referenced
- 2
- Referenced Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
Claim Level Status Information
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.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Claim Status Category Code is limited to category types
A' for batch. For real time acknowledgements category typesA' andE' may be used except for E0. Use of the category typeE' is limited to indicating the business application system is unavailable. - CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 1P
- Provider
- 1Z
- Home Health Care
- 03
- Dependent
- 40
- Receiver
- 41
- Submitter
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- 82
- Rendering Provider
- 85
- Billing Provider
- 87
- Pay-to Provider
- DK
- Ordering Physician
- DN
- Referring Provider
- DQ
- Supervising Physician
- FA
- Facility
- GB
- Other Insured
- HK
- Subscriber
- IL
- Insured or Subscriber
- LI
- Independent Lab
- MSC
- Mammography Screening Center
- PR
- Payer
- PRP
- Primary Payer
- QB
- Purchase Service Provider
- QC
- Patient
- QD
- Responsible Party
- SEP
- Secondary Payer
- TL
- Testing Laboratory
- TTP
- Tertiary Payer
- TU
- Third Party Repricing Organization (TPO)
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- STC02 is the effective date of the status information.
Code indicating type of action
- U
- Reject
- WQ
- Accept
Monetary amount
- STC04 is the amount of original submitted charges.
- Zero is an acceptable amount.
- Sum of the charges (CLM02) submitted from original claim. If an original claim is split, report the original claim total here. Note that this amount may be reported in two or more claims.
Required if additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required if additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Free-form message text
- STC12 allows additional free-form status information.
- See Section 1.4.2.1 for more information on use of STC12 and Status Code `448'.
Payer Claim Control Number
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.
Code qualifying the Reference Identification
- 1K
- Payor's Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Claim Identifier For Transmission Intermediaries
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.
Code qualifying the Reference Identification
- D9
- Claim Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Institutional Bill Type Identification
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.
Code qualifying the Reference Identification
- BLT
- Billing Type
Use this code only for an Institutional Claim.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- See 837 Institutional Implementation Guide for definition of Institutional Bill Type components.
Concatenate the 837I CLM05-1 (Facility Type Code) and CLM05-3 (Claim Frequency Code) values. Code Source = 236 - Uniform Billing Claim Form Bill Type, Code Source 235 - Claim Frequency Type Code respectively.
Claim Level Service Date
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).
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Service Line Information
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.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- AD
- American Dental Association Codes
- ER
- Jurisdiction Specific Procedure and Supply Codes
This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used:
If a new rule names the Jurisdiction Specific Procedure and Supply Codes as an allowable code set under HIPAA,
OR
The Secretary grants an exception to use the code set as a pilot project as allowed under the law,
OR
For claims which are not covered under HIPAA. - HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
- HP
- Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
- NU
- National Uniform Billing Committee (NUBC) UB92 Codes
This is the NUBC code.
- WK
- Advanced Billing Concepts (ABC) Codes
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- If the value in SVC01-1 is "NU", then this element is an NUBC Revenue Code. If the Revenue Code is present in SVC01-2, then SVC04 is not used.
- Value submitted on the original claim.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
Monetary amount
- SVC02 is the submitted service charge.
- Zero is an acceptable amount.
Identifying number for a product or service
- SVC04 is the National Uniform Billing Committee Revenue Code.
Numeric value of quantity
- SVC07 is the original submitted units of service.
Service Line Level Status Information
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.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- For this business application acknowledgment, use of the Claim Status Category Code is limited to category types
A' for batch. For real time acknowledgements category typesA' andE' may be used except for E0. Use of the category typeE' is limited to indicating the business application system is unavailable. - CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- 1P
- Provider
- 1Z
- Home Health Care
- 03
- Dependent
- 40
- Receiver
- 41
- Submitter
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- 82
- Rendering Provider
- 85
- Billing Provider
- 87
- Pay-to Provider
- DK
- Ordering Physician
- DN
- Referring Provider
- DQ
- Supervising Physician
- FA
- Facility
- GB
- Other Insured
- HK
- Subscriber
- IL
- Insured or Subscriber
- LI
- Independent Lab
- MSC
- Mammography Screening Center
- PR
- Payer
- PRP
- Primary Payer
- QB
- Purchase Service Provider
- QC
- Patient
- QD
- Responsible Party
- SEP
- Secondary Payer
- TL
- Testing Laboratory
- TTP
- Tertiary Payer
- TU
- Third Party Repricing Organization (TPO)
Required if additional clarification to STC01 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Required if additional clarification to STC01 and STC10 is needed. If not required by this implementation guide, do not send.
Code indicating a code from a specific industry code list
- C043-01 is used to specify the logical groupings of Health Care Claim Status Codes (See Code Source 507).
- See STC01-1 for valid values.
- CODE SOURCE 507: Health Care Claim Status Category Code
Code indicating a code from a specific industry code list
- C043-02 is used to identify the status of an entire claim or a serviceline.
Code Source 508 is referenced unless qualified by C043-04.
- This code provides further detail of the status. See Section 1.4.2 Status Information (STC Segment Usage).
- CODE SOURCE 508: Health Care Claim Status Code
Code identifying an organizational entity, a physical location, property or an individual
- C043-03 identifies the entity associated with the Health Care Claim Status Code.
- See STC01-3 for valid values.
Free-form message text
- STC12 allows additional free-form status information.
- See Section 1.4.2.1 for more information on use of STC12 and Status Code `448'.
Service Line Item Identification
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.
Code qualifying the Reference Identification
- FJ
- Line Item Control Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Pharmacy Prescription Number
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.
Code qualifying the Reference Identification
- XZ
- Pharmacy Prescription Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Service Line Date
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.
Code specifying type of date or time, or both date and time
- 472
- Service
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
Total number of segments included in a transaction set including ST and SE segments
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- Data value in SE02 must be identical to ST02.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 01 - Payer Response
GS*HN*SENDERGS*RECEIVERGS*20230915*140226*000000001*X*005010X214~
ST*277*0003*005010X214~
BHT*0085*08*277X2140003*20230221*1025*TH~
HL*1**20*1~
NM1*PR*2*YOUR INSURANCE COMPANY*****PI*YIC01~
TRN*1*0091182~
DTP*050*D8*20230220~
DTP*009*D8*20230221~
HL*2*1*21*1~
NM1*41*1*JONES*HARRY*B***46*S00003~
TRN*2*2002022045678~
STC*A1>19>PR*20230221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~
HL*3*2*19*1~
NM1*85*1*JONES*HARRY*B**MD*FI*234567894~
HL*4*3*PT~
NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
TRN*2*PATIENT22222~
STC*A2>20*20230221*WQ*100~
REF*1K*220216359803X~
DTP*472*D8*20230214~
HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*A3>21*20230221*U*65******A3>187~
DTP*472*D8*20230229~
HL*6*3*PT~
NM1*QC*1*JONES*LARRY****MI*4444444444~
TRN*2*JONES44444~
STC*A7>21*20230221*U*100******A7>249~
DTP*472*D8*20230211~
HL*7*3*PT~
NM1*QC*1*JOHNSON*MARY****MI*5555555555~
TRN*2*JOHNSON55555~
STC*A2>20*20230221*WQ*50.5~
REF*1K*220216359806X~
DTP*472*D8*20230210~
HL*8*3*PT~
NM1*QC*1*MILLER*HARRIETT****MI*6666666666~
TRN*2*MILLS66666~
STC*A2>20*20230221*WQ*50~
REF*1K*220216359807X~
DTP*472*D8*20230205~
SE*46*0003~
GE*1*000000001~
IEA*1*000000001~
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