Claim Inquiry Transaction (Batch)
The 276 Transaction Set is used to transmit health care claim status request/response inquiries from health care providers, clearinghouses and other health care claims adjudication processors. The 276 Transaction Set can be used to make an inquiry about a claim or claims for specific SoonerCare members.
It is mandatory under HIPAA that the OKMMIS can accept this transaction set to create health care claim status responses. Key Notes:
- The 276 should be limited to 5,000 inquiries per transaction set (ST-SE envelope).
- In order to return valid claim data on the 277, the data in the 276 must match the data on the claim.
- The hierarchy of the search criteria in the EDI system is:
- NPI/Provider ID
- Recipient ID
- Recipient ID and Name must match
- Amount Billed
- Date of Service
Claim Inquiry Response Transaction (Batch)
The 277 Transaction Set is used to transmit health care claim status inquiry responses to any health care provider, clearinghouse or other health care claims adjudication processors that have submitted a 276 to the OKMMIS. Key Notes:
- The 277 is used solely as a response to a 276 request. The 277- Unsolicited (version 3050) is not the same thing. Refer to Section H for more information on RAs and the 277-Unsolicited.