EDI 276 Health Care 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

3. 0300 · REF · Reference Information · Max 10 · Optional

   To specify identifying information

4. 1000 Loop Optional Repeat >1

   1. 0400 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

   2. 0500 · N2 · Additional Name Information · Max 2 · Optional

      To specify additional names

   3. 0600 · N3 · Party Location · Max 2 · Optional

      To specify the location of the named party

   4. 0700 · N4 · Geographic Location · Max 1 · Optional

      To specify the geographic place of the named party

   5. 0800 · REF · Reference Information · Max 2 · Optional

      To specify identifying information

   6. 0900 · 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. 0100 · HL · Hierarchical Level · Max 1 · Mandatory

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

   2. 0200 · 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. 0300 · PAT · Patient Information · Max 1 · Optional

      To supply patient information

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

   4. 0400 · 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. 0500 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

      2. 0600 · N3 · Party Location · Max 2 · Optional

         To specify the location of the named party

      3. 0700 · N4 · Geographic Location · Max 1 · Optional

         To specify the geographic place of the named party

      4. 0800 · 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. 0900 · TRN · Trace · Max 1 · Mandatory

         To uniquely identify a transaction to an application

      2. 1000 · REF · Reference Information · Max 9 · Optional

         To specify identifying information

      3. 1100 · AMT · Monetary Amount Information · Max 1 · Optional

         To indicate the total monetary amount

      4. 1200 · 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. 1300 · SVC · Service Information · Max 1 · Mandatory

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

         2. 1400 · REF · Reference Information · Max 1 · Optional

            To specify identifying information

         3. 1500 · DTP · Date or Time or Period · Max 1 · Optional

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

         4. 1550 · TOO · Tooth Identification · Max >1 · Optional

            To identify a tooth by number and, if applicable, one or more tooth surfaces

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)