EDI 277 Health Care Claim Status Notification

Functional Group HN

X12N Insurance Subcommittee

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim 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. 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. 010 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 020 · 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

3. 030 · REF · Reference Numbers · Max 10 · Optional

   To specify identifying numbers.

4. 1000 Loop Optional Repeat >1

   1. 040 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

   2. 050 · N2 · Additional Name Information · Max 2 · Optional

      To specify additional names or those longer than 35 characters in length

   3. 060 · N3 · Address Information · Max 2 · Optional

      To specify the location of the named party

   4. 070 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 080 · REF · Reference Numbers · Max 2 · Optional

      To specify identifying numbers.

   6. 090 · PER · Administrative Communications Contact · Max 1 · Optional

      To identify a person or office to whom administrative communications should be directed

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 010 · HL · Hierarchical Level · Max 1 · Mandatory

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

   2. 020 · SBR · Subscriber Information · Max 1 · Optional

      To record information specific to the primary insured and the insurance carrier for that insured

      The SBR segment may only appear at the Subscriber (HL03=22) level.

   3. 030 · PAT · Patient Information · Max 1 · Optional

      To supply patient information

      The PAT segment may only appear at the Dependent (HL03=23) level.

   4. 040 · DMG · Demographic Information · Max 1 · Optional

      To supply demographic information

      The DMG segment may only appear at the Subscriber (HL03=22) or Dependent (HL03=23) level.

   5. 2100 Loop Optional Repeat >1

      1. 050 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 060 · N3 · Address Information · Max 2 · Optional

         To specify the location of the named party

      3. 070 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      4. 080 · PER · Administrative Communications Contact · Max 1 · Optional

         To identify a person or office to whom administrative communications should be directed

   6. 2200 Loop Optional Repeat >1

      1. 090 · TRN · Trace · Max 1 · Mandatory

         To uniquely identify a transaction to an application.

      2. 100 · STC · Status Information · Max 1 · Mandatory

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

      3. 110 · REF · Reference Numbers · Max 3 · Optional

         To specify identifying numbers.

      4. 120 · DTP · Date or Time or Period · Max 2 · Optional

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

      5. 2210 Loop Optional Repeat >1

         1. 130 · PWK · Paperwork · Max 1 · Mandatory

            To identify the type and transmission of paperwork or supporting information

            The 2210 loop is only used when there is a request for additional information about a particular claim.

         2. 140 · PER · Administrative Communications Contact · Max 1 · Optional

            To identify a person or office to whom administrative communications should be directed

         3. 150 · N1 · Name · Max 1 · Optional

            To identify a party by type of organization, name and code

         4. 160 · N3 · Address Information · Max 1 · Optional

            To specify the location of the named party

         5. 170 · N4 · Geographic Location · Max 1 · Optional

            To specify the geographic place of the named party

      6. 2220 Loop Optional Repeat >1

         1. 180 · SVC · Service Information · Max 1 · Mandatory

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

         2. 190 · STC · Status Information · Max 1 · Mandatory

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

         3. 200 · REF · Reference Numbers · Max 1 · Optional

            To specify identifying numbers.

         4. 210 · DTP · Date or Time or Period · Max 1 · Optional

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

         5. 2225 Loop Optional Repeat >1

            1. 220 · PWK · Paperwork · Max 1 · Mandatory

               To identify the type and transmission of paperwork or supporting information

               The 2225 loop is only used when there is a request for additional information about a particular service line.

            2. 230 · PER · Administrative Communications Contact · Max 1 · Optional

               To identify a person or office to whom administrative communications should be directed

            3. 240 · N1 · Name · Max 1 · Optional

               To identify a party by type of organization, name and code

            4. 250 · N3 · Address Information · Max 1 · Optional

               To specify the location of the named party

            5. 260 · N4 · Geographic Location · Max 1 · Optional

               To specify the geographic place of the named party

2. 270 · 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).