277 STATUS RESPONSE - Outbound Translation

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1 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG INTECHANGE CONTOL HEADE IA01 Auth Infmation 00 No auth info present 03 Additional data infmation B3 2 2 The following group of segments is found in Appendix B3 of the Implementation Guide. IA02 Authization Infmation B IA03 ecurity Info 00 No info present B Passwd IA04 ecurity Infmation B IA05 Interchange ID ZZ Mutually Defined B4 2 2 NHP uses ZZ Mutually Defined as the default. (Appendix B4 - IA05) IA06 Interchange ender ID B The Trading Partner agreement determines the Interchange ender ID number. ender number will be mutually defined as indicated in IA05 (IA06) IA07 Interchange ID ZZ Mutually Defined B4 2 2 NHP uses ZZ Mutually Defined as the default. (Appendix B4 - IA05) IA08 Interchange eceiver ID B This is the NHP number that the sender assigned (IA08) IA09 Interchange Date YYMMDD B5 6 6 IA10 Interchange Time HHMM B5 4 4 IA11 Interchange Control tds. U B5 1 1 Identifier IA12 Interchange Control Version No B5 5 5 IA13 Interchange Control No. B5 9 9 This numeric field must be the same as IEA02, Change Control Trailer, Interchange Control No. IA14 Acknowledgment equested 0 No acknowledgement requested B6 1 1 IA15 Usage Indicat P Production data T Test data ize IA16 Component Element eparat B6 1 1 B6 1 1 Our Trading Partner agreement specifies that NHP will determine when file is put in production. NHP will notify the sender via phone. (IA15) FUNCTIONAL GOUP HEADE G01 Functional ID Code HN Health Care Claim tatus B8 2 2 Notification (277) G02 Application ender's Code B Application enders Code and other Functional Group Header infmation is coded as agreed to in our Trading Partner Agreement with you. (G02) G03 Application eceiver's Code B Code agreed to in Trading Partner Agreement (G03) G04 Date Fmat CCYYMMDD B8 8 8 G05 Time Fmat HHMM B9 4 8 G06 Group Control No. Numeric B9 1 9 G006 must match GE02 (Functional Group Trailer). ender assigns the number. 277 Companion Guide el 1v0 - Appendix E.xls 1 of 8 Published October 2003

2 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG ize G07 esponsible Agency Code X Accredited tandards B9 1 2 Committee X 12 G08 Version/elease/Industry ID Code X093A1 B TANACTION ET HEADE T01 Transaction et Identifier Code T02 Transaction et Control The value in T02 must be identical to E02 BEGINNING OF HIEACHICAL TANACTION BHT01 Hierarchical tructure Code 0010 Infmation ource, Infmation eceiver, Provider of ervice, ubscriber, Dependent BHT02 Transaction et Purpose Code 08 tatus BHT03 eference Identification NHP + Timestamp BHT04 Transaction et Creation Date Fmat CCYYMMDD BHT06 Transaction Type Code DG esponse A INFOMATION OUCE LEVEL HL01 Hierarchical ID HL03 Hierarchical Level Code 20 Infmation ource HL04 Hierarchical Child Code 1 Additional subdinate HL Data egment in this Hierarchical tructure A PAYE NAME NM101 Payer Entity ID Code P Payer NM102 Payer Entity Type 2 Non-Person Entity NM103 Payer Name NHP NM108 Payer Identification Code PI Payer Identification NM109 Payer Identification Code A PAYE CONTACT INFOMATION PE01 Payer Contact Function Code IC Infmation Contact PE02 Payer Contact Name Claims esolution PE03 Payer Communication TE Telephone PE04 Payer Contact Communication Companion Guide el 1v0 - Appendix E.xls 2 of 8 Published October 2003

3 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG 2000B INFOMATION ECEIVE LEVEL ize HL01 Hierarchical ID HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 21 Infmation eceiver HL04 Hierarchical Child Code 1 Additional ubdinate HL Data egment in this Hierarchical tructure B INFOMATION ECEIVE NAME epeat:1 NM101 ender Entity ID Code 41 UBMITTE NM102 ender Entity Type 1 Person Non-Person Entity NM103 ender Name Last Organization Name NM104 ender First Name NM105 ender Middle Name NM107 ender Name uffix NM108 ender Identification Code 46 Electronic Transmitter Identification (ETIN) NM109 ender Identification Code C EVICE POVIDE LEVEL HL01 Hierarchical ID HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 19 Provider of ervice HL04 Hierarchical Child Code 1 Additional ubdinate HL Data egment in this Hierarchical tructure C POVIDE NAME NM101 Provider Entity ID Code 1P Provider NM102 Provider Entity Type 1 Person Non-Person Entity NM103 Provider Last Organization Name NM104 Provider First Name NM105 Provider Middle Name NM106 Provider Name Prefix NM107 Provider Name uffix Companion Guide el 1v0 - Appendix E.xls 3 of 8 Published October 2003

4 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG ize NM108 Provider Identification Code V ervice Provider NM109 Provider Identification Code D 2000D 2100D UBCIBE LEVEL epeat:1 NHP members and dependents are all viewed as ubscribers. HL01 Hierarchical ID HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 22 ubscriber HL04 Hierarchical Child Code 0 No ubdinate HL egment in this Hierarchical tructure UBCIBE DEMOGAPHIC INFOMATION This segment is required by NHP because NHP treats each patient as a subsriber. DMG01 Date Time Period Fmat D8 Date expressed in fmat CCYYMMDD DMG02 Date Time Period / ubscriber birth date DMG03 ubscriber Gender Code F Female M Male U Unknown UBCIBE NAME NHP members and dependents are all viewed as ubscribers. NM101 ubscriber Entity ID Code IL ubscriber/insured NM102 ubscriber Entity Type 1 Person NM103 ubscriber Last Name NM104 ubscriber First Name NM105 ubscriber Middle Name NM106 ubscriber Name Prefix NM107 ubscriber Name uffix NM108 ubscriber Identification Code MI Member ID NM109 ubscriber Identification Code NHP Member ID 2200D CLAIM UBMITTE TACE NUMBE TN01 Trace Type Code 2 eferenced Transaction Trace s epeat:1 Infmation will be returned if provided on the incoming 276 request. 277 Companion Guide el 1v0 - Appendix E.xls 4 of 8 Published October 2003

5 =equires, =ituational, N=Not Used egment TN TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG eference Identification/Trace ize D CLAIM LEVEL TATU INFOMATION TC01 TC01-1 HEALTH CAE CLAIM TATU Categy Code F0 Finalized - The claim/encounter has completed the adjudication cycle and no me action will be taken. P1 Pending/In Process - The claim encounter is in the adjudication system. A4 Acknowledgement/Not Found - The claim/encounter cannot be found in the adjudication system. 154 * * TC01-2 tatus Code 1 F me detailed infmation, see remittance advice 3 Claim has been adjudicated and is awaiting payment cycle 20 Accepted f processing 35 Claim/encounter not found TC02 Date of tatus TC04 Total Claim Charge Amount TC05 Claim Payment Amount TC06 Payment Date TC07 Payment Method Code CHK Check Blank if not paid TC08 Check Issue Date TC09 Check D PAYMENT CLAIM IDENTIFICATION NUMBE EF01 eference Identification 1K Payer's Claim EF02 eference Identification D 2200D INTITUTIONAL BILL TYPE IDENTIFICATION EF01 eference Identification BLT Billing Type EF02 eference Identification Bill Type Identifier epeat:1 MEDICAL ECOD IDENTIFICATION Infmation will be returned if provided on the incoming 276 request. EF01 eference Identification EA Medical ecd ID EF02 eference Identification Companion Guide el 1v0 - Appendix E.xls 5 of 8 Published October 2003

6 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG 2200D CLAIM EVICE DATE DTP01 Claim Date/Time 232 Claim tatement Period tart DTP02 Claim Date Time Period D8 ange of Dates expressed in Fmat fmat CCYYMMDD - CCYYMMDD DTP03 Claim Date Time Period ervice period date expressed as CCYYMMDD-CCYYMMDD D EVICE LINE INFOMATION VC01 ervice Line Composite Medical Procedure Identifier 174 * * ize VC01-1 ervice Line Product/ervice ID AD American Dental Association Codes HC HCPC Codes ID IC Codes NU NUBC UB92 Codes VC01-2 ervice Line Product/ervice ID VC01- ervice Line Procedure Modifier VC01- ervice Line Procedure Modifier VC01- ervice Line Procedure Modifier VC01- ervice Line Procedure Modifier VC02 Line Item Charge Amount Original submitted amount. VC03 Line Provider Paid Amount NHP paid amount. VC04 ervice Line Product/ervice ID VC07 ervice Line Quantity D EVICE LINE TATU INFOMATION TC01 HEALTH CAE CLAIM TATU 177 * * TC01 - Categy Code TC01- tatus Code TC02 Date of tatus Companion Guide el 1v0 - Appendix E.xls 6 of 8 Published October 2003

7 =equires, =ituational, N=Not Used 2220D egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG EVICE LINE ITEM IDENTIFICATION ize Not Used by NHP EF01 ervice Line Item eference Identification FJ Line Item Control D EF02 DTP01 DTP02 ervice Line Item eference Identification EVICE LINE DATE ervice Line Date/Time Date Time Period Fmat Provider submitted line ID ervice D8 ange of Dates expressed in fmat CCYYMMDD - CCYYMMDD DTP03 ervice Line Date Time Period Not Used by NHP 2000E DEPENDENT LEVEL DEPENDENT DEMOGAPHIC INFOMATION NHP does not use this loop to response a status request. 2100E 2200E DEPENDENT NAME CLAIM UBMITTE TACE NUMBE CLAIM LEVEL TATU INFOMATION PAYE CLAIM IDENTIFICATION NUMBE INTITUTIONAL BILL TYPE IDENTIFICATION NHP does not use this loop to response a status request. NHP does not use this loop to response a status request. 2220E MEDICAL ECOD IDENTIFICATION CLAIM EVICE DATE EVICE LINE INFOMATION EVICE LINE TATU INFOMATION EVICE LINE ITEM IDENTIFICATION EVICE LINE DATE NHP does not use this loop to response a status request. TANACTION ET TAILE E01 Transaction egment Count E02 Transaction et Control FUNCTIONAL GOUP TAILE GE01 of Transactions ent B GE02 Group Control No. B Companion Guide el 1v0 - Appendix E.xls 7 of 8 Published October 2003

8 =equires, =ituational, N=Not Used egment 277 TATU EPONE - Outbound Translation ANI 277 Name Allowable Data Values IG ize INTECHANGE CONTOL TAILE IEA01 of Functional Groups B7 1 5 IEA02 Interchange Control No. B Companion Guide el 1v0 - Appendix E.xls 8 of 8 Published October 2003

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