EDI 276 X212 - Claim Status Request

Functional Group HR

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Claim Status Request Transaction Set (276) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a health care payer. This transaction set is not intended to replace the Health Care Claim Transaction Set (837), but rather to occur after the receipt of a claim or encounter information. The request may occur at the summary or service line detail level.

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

   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

      3. 2000C Loop Mandatory 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

            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

               Provider of Service is generic in that this could be the entity that originally submitted the claim (Billing Provider) or may be the entity that provided or participated in some aspect of the health care (Rendering Provider). 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 · 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 request 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.
               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. 0400 · DMG · Subscriber Demographic Information · Max 1 · Optional

               To supply demographic information

               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.

            3. 2100D Loop Mandatory Repeat 1

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

                  To supply the full name of an individual or organizational entity

            4. 2200D Loop Optional Repeat >1

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

                  To uniquely identify a transaction to an application

                  This segment conveys a unique trace or reference number for each 2200D loop. This number will be returned in the 277 response.
                  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 · REF · Payer Claim Control Number · Max 1 · Optional

                  To specify identifying information

                  This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
                  Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.

               3. 1000 · REF · Institutional Bill Type Identification · Max 1 · Optional

                  To specify identifying information

                  Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

               4. 1000 · REF · Application or Location System Identifier · Max 1 · Optional

                  To specify identifying information

                  Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
                  This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.

               5. 1000 · REF · Group Number · Max 1 · Optional

                  To specify identifying information

                  Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

               6. 1000 · REF · Patient Control Number · Max 1 · Optional

                  To specify identifying information

                  Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
                  The maximum number of characters supported for the Patient Control Number is `20'.

               7. 1000 · REF · Pharmacy Prescription Number · Max 1 · Optional

                  To specify identifying information

                  Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.

               8. 1000 · REF · Claim Identification Number For Clearinghouses and Other Transmission Intermediaries · Max 1 · Optional

                  To specify identifying information

                  Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.

               9. 1100 · AMT · Claim Submitted Charges · Max 1 · Optional

                  To indicate the total monetary amount

                  Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.
                  Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.

               10. 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.
                   Required for institutional claims or for professional and dental claims when the service date (Loop 2210) 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.

               11. 2210D Loop Optional Repeat >1

                   1. 1300 · SVC · Service Line Information · Max 1 · Mandatory

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

                      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.
                      Required when requesting status for Service Lines. If not required by this implementation guide, do not send.

                   2. 1400 · REF · Service Line Item Identification · Max 1 · Optional

                      To specify identifying information

                      Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.

                   3. 1500 · DTP · Service Line Date · Max 1 · Mandatory

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

            5. 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

                  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.
                  When the patient is the dependent, the claim status request 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.

               2. 0400 · DMG · Dependent Demographic Information · Max 1 · Mandatory

                  To supply demographic information

               3. 2100E Loop Mandatory Repeat 1

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

                     To supply the full name of an individual or organizational entity

               4. 2200E Loop Mandatory Repeat >1

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

                     To uniquely identify a transaction to an application

                     This segment conveys a unique trace or reference for each 2200E Loop. This number will be returned in the 277 response.

                  2. 1000 · REF · Payer Claim Control Number · Max 1 · Optional

                     To specify identifying information

                     This is the payer's assigned control number, also known as, Internal Control Number (ICN), Document Control Number (DCN), or Claim Control Number (CCN).
                     Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.

                  3. 1000 · REF · Institutional Bill Type Identification · Max 1 · Optional

                     To specify identifying information

                     Required when needed to refine the search criteria on Institutional claims. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                  4. 1000 · REF · Application or Location System Identifier · Max 1 · Optional

                     To specify identifying information

                     Required when the application or location system identifier is known. If not required by this implementation guide, do not send.
                     This identifier will be provided to the Information Receiver by the Information Source through a companion document or other trading partner document. If a payer has multiple adjudication systems processing the same type of claim (e.g. professional or institutional), this identifier can be used to improve status routing and response time.

                  5. 1000 · REF · Group Number · Max 1 · Optional

                     To specify identifying information

                     Required when the patient has a group number and the number is known by the Information Receiver. If not required by this implementation guide, do not send.

                  6. 1000 · REF · Patient Control Number · Max 1 · Optional

                     To specify identifying information

                     Required when the Patient Control Number has been assigned by the service provider. If not required by this implementation guide, do not send.
                     The maximum number of characters supported for the Patient Control Number is `20'.

                  7. 1000 · REF · Pharmacy Prescription Number · Max 1 · Optional

                     To specify identifying information

                     Required when the Pharmacy Prescription Number is needed to refine the search criteria for pharmacy claims. If not required by this implementation guide, do not send.

                  8. 1000 · REF · Claim Identification Number For Clearinghouses and Other Transmission Intermediaries · Max 1 · Optional

                     To specify identifying information

                     Required when a Clearinghouse or other transmission intermediary needs to attach their own unique claim number. If not required by this implementation guide, do not send.

                  9. 1100 · AMT · Claim Submitted Charges · Max 1 · Optional

                     To indicate the total monetary amount

                     Required when needed to refine the search criteria for a specific claim. If not required by this implementation guide, do not send.
                     Not all payer systems retain the original submitted charges. Charges are sometimes changed during processing.

                  10. 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.
                      Required for institutional claims or for professional and dental claims when the service date (Loop 2210) 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.

                  11. 2210E Loop Optional Repeat >1

                      1. 1300 · SVC · Service Line Information · Max 1 · Mandatory

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

                         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.
                         Required when requesting status for Service Lines. If not required by this implementation guide, do not send.

                      2. 1400 · REF · Service Line Item Identification · Max 1 · Optional

                         To specify identifying information

                         Required when needed to refine the search criteria for a specific service line. If not required by this implementation guide, do not send.

                      3. 1500 · DTP · Service Line Date · Max 1 · Mandatory

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

2. 1600 · 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)