276/ /277 Health Care Claim Status Request and Response Real-Time. Basic Instructions. Companion Document

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1 Companion Document 276/ /277 Health Care Claim Status Request and Response Real-Time Basic Instructions This section provides information to help you prepare for the ANSI ASC X Health Care Claim Status Request (276) and the ANSI ASC X Health Care Claim Status Response (277). The remaining sections of this appendix include tables that provide information about 276 and 277 segments and data elements that require specific instructions to efficiently process through Anthem systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Claim Status Request and Response, 276/277, ASC X12N 276/277 (004010X093), May 2000 and the subsequent Addenda (004010X093A1), October 2002, published by the Washington Publishing Co. If not specifically identified in this guide, you should refer to the Implementations Guide for direction on other requirements. EDI Transmission Structure Communications Transport Protocol Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Header (GS) Communications Session Interchange Control Wrap Functional Group 1 Wrap Functional Group 2 Wrap Transaction Set Transaction Set Transaction Set Transaction Set Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) Functional Group Trailer (GE) Functional Group Header (GS) Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) EDI Transaction Structure Envelope Envelope Envelope Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Header Detail Summary Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Communications Transport Protocol Page 1 of 26

2 1 Council for Affordable Quality Health Care (CAQH) CAQH is an unprecedented non-profit alliance of health plans and trade associations focused on achievable, concrete initiatives designed to strengthen the nation s health care system and simplify health care administration. The guidelines created by CAQH CORE Phase I & II provide the foundation for how the HIPAA compliant 270/271 is used. 2 Business Purpose The purpose of generating a 276 Status Request is to obtain the current status of the claim within the adjudication process. This transaction includes information that is necessary for Empire Blue Cross Blue Shield (Empire BCBS) to identify the specific claim in question. The following primary identifiers must be supplied: 1) Patient s First Name, in its entirety (10 characters) Loop 2100D, NM104 (if subscriber is the patient) Loop 2100E, NM104 (if dependent is the patient) 2) Billing Provider NPI Number submitted on the original claim Loop 2100C, NM109 3) Member Number Loop 2100D, NM109 Loop 2100E, NM109 (if dependent has a unique identifier) 4) Claim Submitter Trace Number Loop 2200D, TRN02 Loop 2200E, TRN02 4) Claim Number Loop 2200D, REF02 (if subscriber is the patient) Loop 2200E, REF02 (if dependent is the patient) 5) Date(s) of Service Loop 2200D, DTP03 (if subscriber is the patient) Loop 2200E, DTP03 (if dependent is the patient) 6) Claim Submitted Charges Loop 2200D, AMT02 (if subscriber is the patient) Loop 2200E, AMT02 (if dependent is the patient) 3 HIPAA-Compliant Codes When entering codes in the 276 claim status request, carefully follow the 276/277 Implementation Guide. Use HIPAA-Compliant codes from current versions of the sources listed in Appendix C: External Code Sources. Empire BCBS will accept all HIPAA standard codes, however, acceptance of these codes of modifiers will not alter covered benefits or current payment policies, guidelines or processes. 4 Claims without Dollar Amounts A 277 Response on a member-payable claim, rejected claim, or approved claim without dollar amounts will contain a zero dollar amount in the data element, STC05 Claim Payment Amount and SVC03 Line Item Paid Amount. Also, the following STC data elements will not be included: Page 2 of 26

3 STC08 Check Issue or EFT Effective Date STC09 Check or EFT Trace Number 276/277 Claim Status Request and Response Companion Document - Real-Time 5 Adjusted and Voided Claims A 277 Response will include the final image of an adjusted or voided claim. The original claim will not appear. 6 UPPER CASE Letters Empire BCBS requests that all data be entered in UPPERCASE letters only. 7 Delimiters Empire BCBS accepts any of the standard delimiters as defined by the ANSI standards. We recommend the use of the following common delimiters: Data Element Separator, Asterisk, (*) Sub-Element Separator, Colon, (:) Segment Terminator, Tilde (~) NOTE! The vertical bar or pipe ( ) may only be used as a compound separator. Use of the exclaimation point (!) is strongly discouraged. STC07 Payment Method Code 8 Communication Protocol Specifications HTTPS Connectivity. HTTPS connectivity is available through the internet. HTTPS Setup Steps. Contact EDI Solutions to begin the process of getting setup for HTTPS. 1) EDI Solutions will collect information about your organization. Additionally, you must execute a Trading Partner Agreement if your organization hasn t completed one in the past. 2) You will be assigned a User ID and Password (if submitting in real-time). 3) EDI Solutions will assist you in retrieving a Digital Certificate, if required. 4) You will perform the necessary testing and then be promoted to production. Web Address. Below is the HTTPS URL address where an imbedded 276 message may be sent using the HTTPS protocol for a 277 response. Real-Time URL: HTTPS Message Format. The input parameters as described in the tables below for real-time needs to be provided as input while submitting the 276 request data to the HTTPS connectivity application in order to receive a 277 response message. SOAP Message Format. SOAP uses the same field descriptions as HTTPS, but in SOAP format. You must request WSDL files for SOAP processing. SOAP URL: Page 3 of 26

4 HTTPS and SOAP Metadata - Real-Time Field Name Description Format Example PayloadType Payload Type specifies the type of payload included within a request, Text, one of these values: X12_270_004010X092A1 X12_276_004010X093A1 ProcessingMode Processing Mode indicates Batch or Realtime processing mode. will be: RealTime RealTime PayloadID This is an Identifier that you will use to identify AlphaNumeric, may contain hyphen. the request submitted. EncType Form Data Type multipart/form-data TimeStamp Time and Date Universal Time (UTC) time T15:15:52Z specifying when a message is created and sent to a receiver /#dateTime UserName This is the user name to log into the account. A Password will be associated with the User which allows a request to complete. Your User ID will be assigned. 6 to 12 characters, not case sensitive Password This is the password that 6 to 12 characters, case sensitive pairs with the User field to allow access to the Eligibility request system. Your password will be assigned. SenderID ReceiverID This is the Sender ID from the X12 file being submitted. From ISA06. This is the Receiver ID from the X12 file being submitted. From ISA08. AlphaNumeric AlphaNumeric CORERuleVersion The CORE Rule version that this envelope is using. This value can be used to maintain backward compatibility when parsing/processing messages Payload This contains the file with the X request data HIPAA X Compliant INPUT TYPE="FILE" Page 4 of 26

5 HTTPS Error Messages The following are the different message responses and error notifications that may be received when submitting 276 requests. HTTP 200 Ok. When authorization is passed and interface is successful with eligibility systems, HTTP 200 Ok status code and the 277 response X12 data content will be returned by the application. Authorization Errors. If the username and/or password included in the request are not valid, HTTP 403 Forbidden error response with no data will be returned by the application. Server Errors. When the CAQH connectivity application is not able to process a real-time request due to interface failures or Eligibility system unavailability etc., standard 5xx series error such as HTTP 500 Internal Server Error or HTTP 503 Service will be returned by the application. In this scenario, the 276 request submitter will need to resubmit the request since the application process for 277 message reply failed. 9 Receiver ID NY Trading Partners must utilize as the receiver ID for Real-Time submission. The value must appear in two data elements: 276: ISA08 (Interchange Receiver ID), and GS03 (Application Receiver ID). Receiver ID (276/277 Real-Time) State Receiver ID NY Page 5 of 26

6 10 System Hours of Availability The hours of availability for the 270/271 transaction are 24 hours/7 days per week. If you are submitting a request for a member of another Blue Cross Blue Shield Association plan, please note that the minimal hours of unavailability of the plan of membership may vary. 11 Similar Claims Found When the search criteria submitted (Member ID, Member First and Last Name, Dates of Service, Provider NPI and Total Charges) does not result in a match on the Claim Number (REF 1K ), but does find a series of other claims, a response will be generated with the similar claims. The first occurrence where the claim did not match the claim number will return a status of claim not found. Additional Loop 2200D Subscriber Level or Loop 2200E Dependent Level will be returned with the claim information that match the other search criteria. Page 6 of 26

7 12 Acknowledgements and/or Reports Report Inventory. Real-Time. On submitting a 276 transaction in Real-Time mode, you will receive only one of the following responses: A TA1 transaction will be returned when our application cannot process the ISA-IEA envelope in your submitted 276 transaction. A 997 transaction will be returned when our application determines that submitted 276 transaction does not pass our Level 2 HIPAA validation. A 277 response transaction is returned in all other cases. This will indicate the member s coverage or contain an AAA error segment as explanation. File Specifications. TA1 The TA1 file will contain an ISA segment as a header, will contain 1 or more TA1 segment as described in HIPAA Implementation Guides, and have an IEA segment as a trailer. 997 The TA1 file will contain an ISA segment header and IEA trailer and then contain segments as described in the HIPAA Implementation Guides. Sample TA1 File: ISA*00* *00* *ZZ*RECEIVER *ZZ*SENDER *080131*0859*U*00401* *0*T*^~ TA1* *061024*1006*R*023~ TA1* *061024*1006*R*001~ TA1* *061024*1006*R*021~ TA1* *061024*1006*R*009~ TA1* *061024*1006*R*024~ IEA*0* ~ Sample 997 File ISA*00* *00* *ZZ*RECEIVER *ZZ*SENDER *080131*0859*U*00401* *0*T* GS*FA*RECEIVER*SENDER* *085935*1*X*004010~ ST*997*0001~ AK1*HR*102437~ AK2*276* ~ AK4*1*98*7~ AK5*R*5~ AK9*R* *1*1~ SE*7*0001~ GE*1*1~ IEA*1* ~ Page 7 of 26

8 13 Standardized Claims Responses For the following situations, a standardized STC response will be generated. Note that additional claim status codes may provide future specificity in STC10 and STC11. Standardized Claim Responses Description Claim Not Found Subscriber Not Found Patient Not Found (generic) Claim rejected due to no membership finalized status Claim rejected due to coverage termination finalized status Claim rejected due to coverage termination pending status Claim Rejected for Requested Medical Records finalized status Claim Pending for Requested Medical Records pending status STC Response A4^35 E0^33 E0^97 F2^33 F2^27 F2^108^IL P1^27 P1^108^IL F2^317 P3^317 Claim Rejected for Medical Records but no request has been issued at the time a 276 was received finalized status Claim Pending for Medical Records but no request has been issued at the time a 276 was received pending status Claim rejected for Requested COB Information finalized status Claim pending for Requested COB Information pending status Claim rejected for COB Information but a request has not been issued at the time a 276 was received finalized status Claim pending for COB Information but a request has not been issued at the time a 276 was received pending status F2^317 P1^317 F2^52 F2^57 F2^286 P3^52 P3^57 P3^286 F2^52 F2^57 F2^286 P1^52 P1^57 P1^286 *NOTE: These responses are standard for all lines of business. They are not the only codes returned for all situations, other claim status codes are returned. Page 8 of 26

9 Enveloping This section explains EDI enveloping of the 276 Health Care Claim Status Request transaction that will help you submit requests to Empire BCBS. EDI envelopes control and track communications between you and Empire BCBS. One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 276 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Envelope Envelope Envelope Header Detail Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Page 9 of 26

10 276 Envelope Control Segments Inbound Health Care Claim Status Request - Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. It contains authorization and security information, and identifies the sender, receiver, date, time, and interchange control number. Use the following table with the 276 Implementation Guide. Segment A single patient eligibility inquiry request may be submitted per ISA. If multiple requests are sent, a response will be generated for the first subscriber or dependent request only. ISA ISA No Authorization Information Present Interchange Auth Info Qualifier Control ISA02 (10 Spaces) Enter 10 positions. Header Auth Information ISA No Security Information Present Security Info Qualifier ISA04 (10 Spaces) Enter 10 positions. Security Information ISA05 Interchange ID (See 276 IG, Appendix B.4) Qualifier dependent on interchange sender ID selected. ISA06 Interchange Sender ID (Submitter ID) EDI assigned Submitter ID at the time of enrollment. Format - Fixed length of 15 positions, alphanumeric. Left-justified followed by spaces. Identical to GS02. ISA07 ZZ ZZ - Mutually Defined Interchange ID ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator 276 Health Care Claim Status Request Interchange Control Header (ISA) (See Basic Instructions, 8 Receiver ID) (YYMMDD) (HHMM) U Receiver ID of the state receiving the 276 request. Left-justified followed by spaces. Valid date in YYMMDD format. Valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - Fixed length 9 positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 30 calendar period. Right-justified, filled with leading zeroes. Identical to IEA No Acknowledgment Requested Regardless of value, TA1 will always be returned based on errors in the submitted 276. P, T Submitter ID must be approved to submit production data. P - Production Data; T - Test Data (X) X - 1 character contained in Basic or Extended Character set. must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Page 10 of 26

11 2 276 Health Care Claim Status Request - Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Use the following table with the 276 Implementation Guide. Segment GS Functional Group Header GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency Code GS08 Version / Release / Industry Identifier Code 276 Health Care Claim Status Request Functional Group Header (GS) HR HR - Health Care Claim Status Request (276) (Submitter ID) (See Basic Instructions, 8 Receiver ID) (CCYYMMDD) (HHMM) (Assigned by Sender) X X093A1 EDI assigned Submitter ID at the time of enrollment. Format positions, alphanumeric. Left-justified with no trailing zeroes or spaces. Identical to ISA06. Represents Routing Code (Receiver ID) of the state receiving the 276 request. must be a valid date in CCYYMMDD format. must be a valid time in HHMM format. Format positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 30 calendar period. Left-justified with no trailing zeroes or spaces. Identical to GE02. X - Accredited Standards Committee X12 Operationally used to identify the 276/277 Health Care Claim Status and Response transaction. Page 11 of 26

12 3 276 Health Care Claim Status Request - Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Use the following table with the 276 Implementation Guide. Segment 276 Health Care Claim Status Request Functional Group Trailer (GE) GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (Total Number of Transaction Sets in Functional Group or Transmission) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS Health Care Claim Status Request - Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). Use the following table with the 276 Implementation Guide. Segment 276 Health Care Claim Status Request Interchange Control Trailer (IEA) IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of Functional Groups GS/GE Pairs in Interchange) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. Page 12 of 26

13 276 Health Care Claim Status Request Header IG Segment P.49 ST Transaction Set Header P.50 BHT Beginning of Hierarchical Transaction ST01 Transaction Set Code ST02 Transaction Set Control Number BHT02 Transaction Set Purpose Code BHT04 Date Health Care Claim Status Request (Control Number) Request (Transaction Set Creation Date) is unique and identical to SE02. Date of when 276 transaction was created. Page 13 of 26

14 276 Health Care Claim Status Request Header The 276 Status Request Header identifies the start of the transaction, the specific transaction set, and its business purpose. A data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. 276 Health Care Claim Status Request Detail The 276 Status Request Detail level contains all data relating to the requested transaction, including transaction participants, the patient, all providers, and services detail information. Using a hierarchical level (HL) structure, the five participant types include: 1) Information Source. Decision-maker of the business transaction, known as the Payer. 2) Information Receiver. Receiver of the response from the Information Source. 3) Service Provider. Billing Provider from the originally submitted claim. 4) Subscriber. Member known by the Information Source. 276 Health Care Claim Status Request Detail Information Source Level IG Segment Loop ID 2100A Payer Name P.54 NM1 NM108 Payer Name Code Qualifier NM109 Code AD (See Basic Instructions, 8 Receiver ID) AD - Blue Cross Blue Shield Association Plan Code State Receiver/Sender ID. Page 14 of 26

15 5) Dependent. Individual entitled to health care benefits because of relationship to Subscriber. IG Segment Loop ID 2100B Information Receiver Name P.62 NM1 NM Submitter Information Entity Identifier Receiver Code Name 276 Health Care Claim Status Request Detail Information Receiver Level NM108 Code Qualifier NM109 Code 46 FI XX (Information Receiver Number) 46 - Electronic Transmitter Number (ETIN) FI - Federal Taxpayer's Number XX - HCFA National Provider Identifier EDI Sender ID ('46') - for Clearinghouses Tax ID ('FI') - for Exempt Provider NPI ('XX') 1 Information Source Level Loop 2100A contains the Information Source Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop that are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2100C Provider Name P.67 NM1 NM101 Provider Entity Identifier Name Code NM108 Code Qualifier 276 Health Care Claim Status Request Detail Service Provider Level 1P FI XX 1P - Provider FI - Federal Taxpayer's Number XX - HCFA National Provider Identifier FI may only be used by a Registered Exempt Provider. NM109 Code (Information Receiver ID No.) Federal Taxpayer's Number ('FI') - for Exempt Provider NPI ('XX') Page 15 of 26

16 2 Information Receiver Level Loop 2100B contains the Information Receiver Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2000D Subscriber Level P.72 DMG DMG03 M Subscriber Gender Code F Demographic Information Loop ID 2100D Subscriber Name P.74 NM1 NM102 Subscriber Name Entity Type Qualifier Name NM104 Name First M - Male F - Female Person (Subscriber First Name) NM108 MI ID Code Qualifier NM109 (Subscriber Code Identifier) Format Examples XXX######### XXXX######### XXX###X##### R######## J########## Loop ID 2200D Claim Submitter Trace Number P.78 REF REF02 (Payer Payer Claim Claim Control Number Number) P.80 REF Institutional Bill Type P.82 REF Medical Record P.86 DTP Claim Service Date 276 Health Care Claim Status Request Detail Subscriber Level REF02 REF02 DTP03 Date Time Period (Bill Type Identifier) (Medical Record Number) (Claim Service Period) First name of the subscriber as it appears on the member ID card. Populating this field increases the likelihood for a positive match of the claim in question. MI - Member Number number as it appears on the payers database. Explanation Alphanumeric subscriber identification as it appears on the front of the ID card. Payer's Claim number is populated in this field if known. Represents Type of Bill submitted in 837I, CLM05 data element, and the subscriber is the patient. Medical record number as submitted on original claim, if applicable, and the subscriber is the patient. Date(s) of service. Page 16 of 26

17 3 Service Provider Level Loop 2100C contains the Service Provider Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2000E Dependent Level P.94 HL HL01 Dependent Hierarchical ID Level Number HL02 Hierarchical Parent P.96 DMG Dependent Demographic Information ID Number DMG03 Gender Code Loop ID 2100E Dependent Name P.98 NM1 Dependent Name NM104 Name First (Assigned by Sender) ( Number) M F (Patient First Name) Loop ID 2200E Claim Submitter Trace Number P.103 REF REF02 Payer Claim Number P.105 REF REF02 Institutional Bill Type P.107 REF Medical Record P.111 DTP Claim Service Date 276 Health Care Claim Status Request Detail Dependent Level REF02 DTP03 Date Time Period (Payer Claim Control Number) (Bill Type Identifier) (Medical Record Number) (Claim Service Period) incremented by '1' according to HL level. Identifies the specific hierarchical level to which the current HL is subordinate. M - Male F - Female First name of the patient as it appears on the member ID card. Populating this field increases the likelihood for a positive match of the claim in question. Payer's Claim number is populated in this field if known. Represents Type of Bill submitted in 837I, CLM05 data element, and the patient is not the subscriber. Medical record number as submitted on original claim, if applicable, and the patient is not the subscriber. Date(s) of service. Page 17 of 26

18 Enveloping This section explains EDI enveloping of the 277 Health Care Claim Status Response transaction that will help you when receiving responses from Empire BCBS. EDI envelopes control and track communications between you and Empire BCBS. One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 277 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Envelope Envelope Envelope Header Detail Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Page 18 of 26

19 277 Envelope Control Segments Outbound Health Care Claim Status Response - Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. It contains authorization and security information, and identifies the sender, receiver, date, time, and interchange control number. Use the following table with the 277 Implementation Guide. Segment 277 Health Care Claim Status Request Interchange Control Header (ISA) ISA ISA01 Interchange Auth Information Control ISA02 Header Authorization ISA03 Security Info Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID No Authorization Information Present (10 Spaces) 10 position value populated on 276 inquiry No Security Information Present (10 Spaces) 10 position value populated on 276 inquiry. ZZ (See Basic Instructions, 8 Receiver ID) ZZ ISA07 Interchange ID Qualifier ISA08 (Receiver ID) Interchange Receiver ID ISA09 (YYMMDD) Interchange Date ISA10 (HHMM) Interchange Time ISA11 U Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator ZZ - Mutually Defined Receiver ID populated in ISA08 on 276 inquiry. ZZ - Mutually Defined Submitter ID populated in ISA06 on 276 inquiry. Valid date in YYMMDD format. Valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - 9 position numeric. Unique value greater than zero, not used in previous HIPAA transaction within 30 calendar day period. Right-justified, filled with leading zeroes No Acknowledgment Requested Regardless of value, TA1 will always be returned based on errors in the submitted 276. P, T Submitter ID must be approved to submit production data. P - Production Data; T - Test Data (X) X - 1 character contained in Basic or Extended Character set. not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). Page 19 of 26

20 2 277 Health Care Claim Status Response - Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Segment 277 Health Care Claim Status Response Functional Group Header (GS) GS Functional Group Header GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number HN HN - Health Care Claim Status Response (277) (See Basic Instructions, 8 Receiver ID) *(Receiver ID) (CCYYMMDD) (HHMM) (Assigned by Sender) GS07 X Responsible Agency Code GS X093A1 Version / Release / Industry Identifier Code Represents Routing Code (Sender ID) of the state responding to the 276 inquiry. *Submitter ID populated on 276 inquiry. Valid date in CCYYMMDD format. Valid time in HHMM format. Format position numeric. Unique value greater than zero, not used in previous HIPAA transaction within 30 calendar day period. Right-justified, filled with leading zeroes. Identifical to value in GE02. X - Accredited Standards Committee X12 Operationally used to identify the 276/277 Health Care Claim Status Request and Response transaction. NOTE! A new, unique GS Control Number is assigned to the 277 transaction. Since the original submitted GS Control Number on the 276 transaction is not used, the TRN number is used to match the 277 response to the 276 request. Page 20 of 26

21 3 277 Health Care Claim Status Response - Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Use the following table with the 277 Implementation Guide. Segment 277 Health Care Claim Status Response Functional Group Trailer (GE) GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (Total Number of Transaction Sets in Functional Group or Transmission) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS Health Care Claim Status Response - Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). Use the following table with the 277 Implementation Guide. Segment 277 Health Care Claim Status Response Interchange Control Trailer (IEA) IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of Functional Groups GS/GE Pairs in Interchange) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. Page 21 of 26

22 277 Health Care Claim Status Response Header The 277 Status Response Header identifies the start of the transaction, the specific transaction set, and its business purpose. A data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. 277 Health Care Claim Status Response Header IG Segment P.125 ST Transaction Set Header P.126 BHT Beginning of Hierarchical Transaction ST01 Transaction Set ST02 Transaction Set Control Number BHT03 BHT04 Date Health Care Claim Status Notification (Control Number) (Originator Application Transaction Identifier) (Transaction Set Creation Date) is unique and identical to SE02. Assigned by the originator to identify the transaction. Date of when 277 transaction was created. Page 22 of 26

23 277 Health Care Claim Status Response Detail The 277 Status Response Detail level contains all data relating to the requested transaction, including transaction participants, the patient, all providers, and services detail information. Using a hierarchical level (HL) structure, the five participant types include: 1) Information Source. Decision-maker of the business transaction, known as the Payer. 2) Information Receiver. Receiver of the response from the Information Source. 3) Service Provider. Billing Provider from the originally submitted claim. 4) Subscriber. Member known by the Information Source. 5) Dependent. Individual entitled to health care benefits because of relationship to Subscriber. 1 Information Source Level Loop 2100A contains the Information Source Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop that are used to process efficiently through the Empire BCBS system. 277 Health Care Claim Status Response Detail Information Source Level IG Segment Loop ID 2100A Payer Name P.130 NM1 NM108 Payer Name Code Qualifier NM109 Code AD (Payer Identifier) AD - Blue Cross and Blue Shield Association Plan Code State Receiver/Sender ID populated on 276 Request. Page 23 of 26

24 2 Information Receiver Level Loop 2100B contains the Information Receiver Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop that are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2100B Information Receiver Name P.138 NM1 NM Submitter Information Entity Identifier Receiver Code Name 277 Health Care Claim Status Response Detail Information Receiver Level NM108 Code Qualifier NM109 Code 46 FI XX (Information Receiver Number) 46 - Electronic Transmitter Number (ETIN) FI - Federal Taxpayer's Number XX - HCFA National Provider Identifier EDI Sender ID ('46') - for Clearinghouses Tax ID ('FI') - for Exempt Provider NPI ('XX') 3 Service Provider Level Loop 2100C contains the Service Provider Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in this Loop that are used to process efficiently through the Empire BCBS system. 277 Health Care Claim Status Response Detail Service Provider Level IG Segment Loop ID 2100C Provider Name P.143 NM1 NM101 Provider Entity Identifier Name Code NM108 Code Qualifier 1P FI 24 XX NM109 (Provider Code Identifier) 1P - Provider FI - Federal Taxpayer's Number 24 - Employer's ID No. (Tax ID No.) XX - HCFA National Provider Identifier Tax ID ('FI') - for Exempt Provider Tax ID No. ('24') - for Exempt Provider NPI ('XX') Page 24 of 26

25 4 Subscriber Level Loops 2100D, 2200D and 2220D contain the Subscriber Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in these Loops that are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2000D Subscriber Level P.148 DMG DMG03 Subscriber Gender Code Demographic Information Loop ID 2100D Subscriber Name P.150 NM1 NM104 Subscriber Name First Name NM108 Code Qualifier NM109 Code M F (Subscriber First Name) MI (Subscriber Identifier) Loop ID 2200D Claim Submitter Trace Number P.154 STC STC01-1 (Health Care Claim Level Idustry Code Claim Status Status Category Code) Information P.165 REF Payer Claim Number P.167 REF Institutional Bill Type P.169 REF Medical Record P.171 DTP Claim Service Date 277 Health Care Claim Status Response Detail Subscriber Level STC01-2 Idustry Code STC06 Date STC07 Payment Method Code STC08 Date STC09 Check Number REF02 REF02 REF02 DTP03 Date Time Period (Health Care Claim Status Code) (Adjudication or Payment Date) CHK NON M - Male F - Female Represents the first name of the subscriber populated on 276 Request. MI - Member Number Member/Subscriber ID No. populated on 276 Request. One Category Code populated per claim. One Status Code populated per claim. Date when the claim was adjudicated. CHK - Check NON - Non-payment Data (Check or EFT Date when check was issued. Effective Date) (Check or EFT Check Number Trace Number) (Payer Claim Payer's Claim Number Control Number) (Bill Type Identifier) (Medical Record Number) (Claim Service Period) Bill type as submitted on the original claim when available - required for institutional claim inquiries. Medical record number as submitted on original claim, if applicable, and the subscriber is the patient. Date(s) of service Page 25 of 26

26 5 Dependent Level Loops 2000E, 2100E, 2200E and 2220E contain the Dependent Level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements in these Loops that are used to process efficiently through the Empire BCBS system. IG Segment Loop ID 2000E Dependent Level P.192 DMG DMG03 Dependent Gender Code Demographic Information Loop ID 2100E Dependent Name P.194 NM1 NM104 Dependent Name First Name M F (Dependent First Name) Loop ID 2200E Claim Submitter Trace Number P.199 STC STC01-1 Claim Level Idustry Code Status Information P.210 REF Payer Claim Number P.212 REF Institutional Bill Type P.214 REF Medical Record P.216 DTP Claim Service Date 277 Health Care Claim Status Response Detail Dependent Level STC01-2 Idustry Code STC06 Date (Health Care Claim Status Category Code) (Health Care Claim Status Code) (Adjudication or Payment Date) STC07 CHK Payment Method NON Code STC08 (Check or EFT Date Effective Date) STC09 (Check or EFT Check Number REF02 REF02 REF02 Trace Number) (Payer Claim Control Number) (Bill Type Identifier) (Medical Record Number) DTP03 (Claim Service Date Time Period Period) M - Male F - Female Represents the first name of the subscriber populated on 276 Request. One Category Code populated per claim. One Status Code populated per claim. Date when the claim was adjudicated. CHK - Check NON - Non-payment Data Date when check was issued. Check Number Payer's Claim Number Bill type as submitted on the original claim when available - required for institutional claim inquiries. Medical record number as submitted on original claim, if applicable, and the subscriber is the patient. Date(s) of service. Page 26 of 26