276, 277 EDI transactions details
276, 277 EDI transactions examples are presented below for better understanding of the transaction sets. 276, 277 EDI transactions purposes: the 276 transaction is designed to be exchanged for a 277 response containing the benefit information sought in the 276 request. Should the 276 fail structural validation upon receipt, a 999 acknowledgement file will be returned detailing the specific errors. No 277 response will be generated unless the 276 is corrected and resubmitted. 276, 277 EDI transactions are shown as raw data and human readable format.
276 Request Raw Data Example
This example is a request for two claims. It’s submitted by UCLA MEDICAL CENTER to BCBS Disney (payer). The first request for a status is a claim issued for patient Mickey Mouse for $225; the second claim is for Donald Duck also for $225. For both claims the subscribers are the patient. For Mickey’s claim, provider is asking for a general claim status for Donald’s claim the provider is asking for status on a specific line item.
ST*276*3707*005010X212
BHT*0010*13*ABC276XYZ*20120128*1425
HL*1**20*1
NM1*PR*2*BCBS DISNEY*****PI*8584537845
HL*2*1*21*1
NM1*41*2*UCLA MEDICAL CENTER*****46*1982
HL*3*2*19*1
NM1*1P*2*UCLA MEDICAL CENTER*****XX*1215193883
HL*4*3*22*0
DMG*D8*19281118*M
NM1*IL*1*MOUSE*MICKEY****MI*60345914A
TRN*1*ABC9001
REF*BLT*221
REF*EJ*ABC9001
DTP*472*D8*20120124
HL*5*3*22*0
DMG*D8*19340619*M
NM1*IL*1*DUCK*DONALD****MI*60345914B
TRN*1*ABC9002
REF*BLT*221
REF*EJ*ABC9002
DTP*472*D8*20120124
SVC*HC:98765*150**0450***1
SE*24*3707
276 Human Readable Example
Beginning of Hierarchical Transaction: BHT*0010*13*ABC276XYZ*20120128*1425
Hierarchical Structure Code : Information Source, Information Receiver, Provider of Service, Subscriber,
Transaction Set Purpose Code : Request
Reference Identification : ABC276XYZ
Date : 1/28/2012
Time : 2:25:00 PM
Payer Name: NM1*PR*2*BCBS DISNEY*****PI*8584537845
Entity Identifier Code : Payer
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : BCBS DISNEY
Identification Code Qualifier : Payor Identification
Identification Code : 8584537845
Information Receiver Name: NM1*41*2*UCLA MEDICAL CENTER*****46*1982
Entity Identifier Code : Submitter
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : UCLA MEDICAL CENTER
Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
Identification Code : 1982
Provider Name: NM1*1P*2*UCLA MEDICAL CENTER*****XX*1215193883
Entity Identifier Code : Provider
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : UCLA MEDICAL CENTER
Identification Code Qualifier : Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code : 1215193883
Demographic Information: DMG*D8*19281118*M
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 19281118
Gender Code : Male
Subscriber Name: NM1*IL*1*MOUSE*MICKEY****MI*60345914A
Entity Identifier Code : Insured or Subscriber
Entity Type Qualifier : Person
Name Last or Organization Name : MOUSE
Name First : MICKEY
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914A
Trace: TRN*1*ABC9001
Trace Type Code : Current Transaction Trace Numbers
Reference Identification : ABC9001
Reference Information: REF*BLT*221 and REF*EJ*ABC9001
Billing Type : 221
Patient Account Number : ABC9001
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
Demographic Information: DMG*D8*19340619*M
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 19340619
Gender Code : Male
Individual or Organizational Name: NM1*IL*1*DUCK*DONALD****MI*60345914B
Entity Identifier Code : Insured or Subscriber
Entity Type Qualifier : Person
Name Last or Organization Name : DUCK
Name First : DONALD
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914B
Trace: TRN*1*ABC9002
Trace Type Code : Current Transaction Trace Numbers
Reference Identification : ABC9002
Reference Information: REF*BLT*221 and REF*EJ*ABC9002
Billing Type : 221
Patient Account Number : ABC9002
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
Service Information: SVC*HC:98765*150**0450***1
(HCPCS) , 98765
Charge Amount : 150
Product/Service ID : 0450
Quantity : 1
277 Example Raw Data
This example is a turn-around response to the example above. It is transmitted by BCBS Disney to UCLA MEDICAL CENTER. The TRN-02 element is the key reference element between the 276 and the 277.
The first claim for Mickey Mouse was put on hold pending additional information: STC*P3:60*20120125**225*0. The STC segment (Status Information) provides the status in STC01-01, STC01-02. CODE P3 means “Pending/Provider Requested Information – The claim or encounter is waiting for information that has already been requested from the provider.” CODE 60 means “Electronic request for information.” This means that an unsolicited 277 was sent earlier requesting more information and a response was not received yet from UCLA MEDICAL CENTER.
The second claim for Donald Duck was has been finalized and adjudicated and is waiting a payment cycle. In the following STC segment STC*F1:65*20120128 STC01-01 has Code Category of F1 which means “Finalized/Payment-The claim/line has been paid.” And STC01-02 has a Claim Status Code of 65 which means “Claim/line has been paid.”
More detailed response information is provided below in the raw data and the human readable example.
ST*277*3708*005010X212
BHT*0010*08*ABC276XYZ*20120128*1426*DG
HL*1**20*1
NM1*PR*2*BCBS DISNEY*****PI*8584537845
HL*2*1*21*1
NM1*41*2*UCLA MEDICAL CENTER*****46*1982
HL*3*2*19*1
NM1*1P*2*UCLA MEDICAL CENTER*****XX*1215193883
HL*4*3*22*0
DMG*D8*19281118*M
NM1*QC*1*MOUSE*MICKEY****MI*60345914A
TRN*1*ABC9001
STC*P3:60*20120128**225*0
REF*BLT*221
REF*EJ*ABC9001
DTP*472*D8*20120124
HL*5*3*22*0
DMG*D8*19340619*M
NM1*QC*1*DUCK*DONALD****MI*60345914B
TRN*1*ABC9002
REF*BLT*221
REF*EJ*ABC9002
DTP*472*D8*20120124
SVC*HC:98765*150**0450***1
STC*F1:65*20120128
SE*26*3708
277 Human Readable Example
Beginning of Hierarchical Transaction: BHT*0010*08*ABC276XYZ*20120128*1426*DG
Hierarchical Structure Code : Information Source, Information Receiver, Provider of Service, Subscriber,
Transaction Set Purpose Code : Status
Reference Identification : ABC276XYZ
Date : 1/28/2012
Time : 2:26:00 PM
Transaction Type Code : Response
Payer Name: NM1*PR*2*BCBS DISNEY*****PI*8584537845
Entity Identifier Code : Payer
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : BCBS DISNEY
Identification Code Qualifier : Payor Identification
Identification Code : 8584537845
Information Receiver Name: NM1*41*2*UCLA MEDICAL CENTER*****46*1982
Entity Identifier Code : Submitter
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : UCLA MEDICAL CENTER
Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
Identification Code : 1982
Provider Name: NM1*1P*2*UCLA MEDICAL CENTER*****XX*1215193883
Entity Identifier Code : Provider
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : UCLA MEDICAL CENTER
Identification Code Qualifier : Centers for Medicare and Medicaid Services National Provider Identifier
Identification Code : 1215193883
Demographic Information: DMG*D8*19281118*M
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 19281118
Gender Code : Male
Patient Name: NM1*QC*1*MOUSE*MICKEY****MI*60345914A
Entity Identifier Code : Patient
Entity Type Qualifier : Person
Name Last or Organization Name : MOUSE
Name First : MICKEY
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914A
Trace: TRN*1*ABC9001
Trace Type Code : Current Transaction Trace Numbers
Reference Identification : ABC9001
Status Information: STC*P3:60*20120128**225*0
Health Care Claim Status : P3 , 60 – Suspended Pending More Information
Date : 1/28/2012
Monetary Amount : 225
Monetary Amount : 0
Reference Information: REF*BLT*221 and REF*EJ*ABC9001
Billing Type : 221
Patient Account Number : ABC9001
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
Demographic Information: DMG*D8*19340619*M
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 19340619
Gender Code : Male
Patient Name: NM1*QC*1*DUCK*DONALD****MI*60345914B
Entity Identifier Code : Patient
Entity Type Qualifier : Person
Name Last or Organization Name : DUCK
Name First : DONALD
Identification Code Qualifier : Member Identification Number
Identification Code : 60345914B
Trace: TRN*1*ABC9002
Trace Type Code : Current Transaction Trace Numbers
Reference Identification : ABC9002
Reference Information: REF*BLT*221 and REF*EJ*ABC9002
Billing Type : 221
Patient Account Number : ABC9002
Date or Time or Period: DTP*472*D8*20120124
Date/Time Qualifier : Service
Date Time Period Format Qualifier : Date Expressed in Format CCYYMMDD
Date Time Period : 20120124
Service Information: SVC*HC:98765*150**0450***1
(HCPCS) , 98765
Monetary Amount : 150
Product/Service ID : 0450
Quantity : 1
Status Information: STC*F1:65*20120128
Health Care Claim Status : F1 , 65 Finalized The Claim Line Has Been Paid
Date : 1/28/2012.
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