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
- 0100Transaction Set HeaderMandatoryMax 1
To indicate the start of a transaction set and to assign a control number
- 0200Beginning of Hierarchical TransactionMandatoryMax 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
- 2000A Loop MandatoryRepeat 1
- 0100Information Source LevelMandatoryMax 1
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. - 2100A Loop MandatoryRepeat 1
- 0500Information Source NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 0500Information Source NameMandatoryMax 1
- 2200A Loop MandatoryRepeat 1
- 0900Transmission Receipt Control IdentifierMandatoryMax 1
To uniquely identify a transaction to an application
- 1200Information Source Receipt DateMandatoryMax 1
To specify any or all of a date, a time, or a time period
- 1200Information Source Process DateMandatoryMax 1
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.
- 0900Transmission Receipt Control IdentifierMandatoryMax 1
- 2000B Loop MandatoryRepeat 1
- 0100Information Receiver LevelMandatoryMax 1
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. - 2100B Loop MandatoryRepeat 1
- 0500Information Receiver NameMandatoryMax 1
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.
- 0500Information Receiver NameMandatoryMax 1
- 2200B Loop MandatoryRepeat 1
- 0900Information Receiver Application Trace IdentifierMandatoryMax 1
To uniquely identify a transaction to an application
This segment contains the value submitted in the BHT03 data element from the 837. - 1000Information Receiver Status InformationMandatoryMax >1
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. - 1210Total Accepted QuantityOptionalMax 1
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. - 1210Total Rejected QuantityOptionalMax 1
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. - 1220Total Accepted AmountOptionalMax 1
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. - 1220Total Rejected AmountOptionalMax 1
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.
- 0900Information Receiver Application Trace IdentifierMandatoryMax 1
- 2000C Loop OptionalRepeat >1
- 0100Billing Provider of Service LevelMandatoryMax 1
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). - 2100C Loop MandatoryRepeat 1
- 0500Billing Provider NameMandatoryMax 1
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.
- 0500Billing Provider NameMandatoryMax 1
- 2200C Loop OptionalRepeat 1
- 0900Provider of Service Information Trace IdentifierMandatoryMax 1
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). - 1000Billing Provider Status InformationOptionalMax >1
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. - 1100Provider Secondary IdentifierOptionalMax 3
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. - 1210Total Accepted QuantityOptionalMax 1
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. - 1210Total Rejected QuantityOptionalMax 1
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. - 1220Total Accepted AmountOptionalMax 1
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. - 1220Total Rejected AmountOptionalMax 1
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.
- 0900Provider of Service Information Trace IdentifierMandatoryMax 1
- 2000D Loop OptionalRepeat >1
- 0100Patient LevelMandatoryMax 1
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. - 2100D Loop MandatoryRepeat 1
- 0500Patient NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 0500Patient NameMandatoryMax 1
- 2200D Loop MandatoryRepeat >1
- 0900Claim Status Tracking NumberMandatoryMax 1
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. - 1000Claim Level Status InformationMandatoryMax >1
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. - 1100Payer Claim Control NumberOptionalMax 1
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. - 1100Claim Identifier For Transmission IntermediariesOptionalMax 1
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. - 1100Institutional Bill Type IdentificationOptionalMax 1
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. - 1200Claim Level Service DateMandatoryMax 1
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). - 2220D Loop OptionalRepeat >1
- 1800Service Line InformationMandatoryMax 1
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. - 1900Service Line Level Status InformationMandatoryMax >1
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. - 2000Service Line Item IdentificationMandatoryMax 1
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. - 2000Pharmacy Prescription NumberOptionalMax 1
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. - 2100Service Line DateOptionalMax 1
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.
- 1800Service Line InformationMandatoryMax 1
- 0900Claim Status Tracking NumberMandatoryMax 1
- 0100Patient LevelMandatoryMax 1
- 0100Billing Provider of Service LevelMandatoryMax 1
- 0100Information Receiver LevelMandatoryMax 1
- 0100Information Source LevelMandatoryMax 1
- 2700Transaction Set TrailerMandatoryMax 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)