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EDI 277 Format Example

EDI 277 Healthcare Claim Acknowledgment


What is the EDI 277CA Transaction Set?

The EDI 277CA Healthcare Claim Acknowledgment provides a claim-level acknowledgment of all claims received in the payer’s pre-processing system before submitting claims into an adjudication system. It is created in receipt of an incoming EDI 837 5010 claim submission transaction. The 277CA offers a common report interface to payers and providers. The 277A is designed to give clearinghouses and payers a standardized reporting mechanism for 5010. The 277 CA is not required by HIPAA.

The general acknowledgment workflow would be that the provider sends an EDI 837 to the payer. The payer or clearinghouse returns an EDI 999 to acknowledge receipt of the 837. The payer or clearinghouse may send the 277CA. If the 837 is rejected, the payer may next send EDI 275.

 

Healthcare Claim and Encounter plus Additional Supporting Information

Provider initiated coordination of benefits occurs here:

837 Healthcare Claim: Professional
837 Healthcare Claim: Institutional
837 Healthcare Claim: Dental

837 Healthcare Service Data Reporting
277 Healthcare Claim Acknowledgment
275 Additional Information to Support a Healthcare Claim or Encounter

Source: x12.org/flow/health-care

 

The 277CA reports on whether pre-adjudication validation found the claim acceptable for adjudication. The 277CA Health Care Claim Acknowledgment includes basic file information:

  • Submission status 
  • Submission date 
  • Claims submitted 
  • Claims rejected 
  • Claims accepted 
  • Reasons for claim rejections 

The 277CA reports status of either accepted or rejected in the STC Segments. It does not have the functionality to report ‘warnings’ that did not lead to a rejected status. The 277CA cannot report syntax issues. It can reject a claim for the syntax issues previously identified in the 999 that was accepted with error(s).

Look to the STC segment as the key element for providing the status notification. The STC segment consists of Claim Status Categories, Claim Status Codes and monetary amounts. Some example codes are:

 

A0Acknowledgment ForwardedThe claim has been forwarded to another entity, such as a repricing service.
A1Acknowledgment ReceiptThe claim has been received.
A2Acknowledgment AcceptedThe claim has been accepted into the adjudication system.
A3Acknowledgment Returned as Unable to Process The claim has been rejected and has not been entered into the adjudication system.
A5Acknowledgment Split ClaimThe claim has been split upon acceptance into the adjudication system.
A6Acknowledgment Rejected for Missing InformationThe claim is missing information specified in status details and has been rejected.
A7Acknowledgment Rejected for Invalid Information The claim has invalid information as specified in the status details and has been rejected.
A8Acknowledgment Rejected for Relational Filed in Error

 

The Health Care Claim Acknowledgment Implementation Guide describes the use of the X12 Health Care Information Status Notification (277CA) transaction set to acknowledge receipt of electronically submitted claim data and indicate the data’s acceptance, rejection or forwarding to another entity.

For more information about X12 EDI 277CA, refer to x12.org as well as  x12.org/codes and TR3 Implementation Guide (Technical Report Type 3).

EDI 277CA Format Example

ASC X12 Version: 005010 | Transaction Set: 277 | TR3 ID: 005010X364

Example

In the following example, Your Insurance Company (Electronic Transmitter ID Number S00003) submitted an 837 Post Adjudicated Claims Data Reporting Professional file with an Originator Application Transaction Identifier of 206438976580901 in BHT03 directly to “All Payer Claim Database” (Electronic Transmitter ID Number APCD01) on February 20, 2019.

“All Payer Claim Database” processed the file on February 21, 2019 and notified Your Insurance Company that although the file containing five claims for charges totaling $365.50 was accepted, there were two individual claims that were rejected and one received a warning. Following is the status information for the claims contained in the 837 transmission file:

The following claims were for provider Harry B Jones, MD (NPI 1546326897):
Female Patient’s (Member ID Number 2222222222) claim for $100.00 for date of service February 14, 2019 was accepted. The payer claim control number is 220216359803X. The All Payer Claim Database assigned a data receiver claim control number of IC429783.

Male Patient’s (Member ID Number 3333333333) claim for $65.00 was rejected for an invalid diagnosis code. The payer claim control number is 220216359954X. The All Payer Claim Database assigned a data receiver claim control number of IC847502.

Larry Jones’ (Member ID Number 4444444444) claim for $100.00 for date of service February 11, 2019 was rejected because the place of service was missing or invalid. The payer claim control number is 220216359964X. The All Payer Claim Database assigned a data receiver claim control number of IC429805.

For provider John C. Smith, there is an additional location identifier of AB142 that is sent.

The following claims were for provider John C. Smith, MD (NPI 1546326780):
Mary Johnson’s (Member ID Number 5555555555) claim for $50.50 for date of service February 10, 2019 was accepted but an exception occurred (STC03 = EZ). The warning given at the line level was for a procedure code not valid for the patient’s age. The payer claim control number is 220216359806X. The All Payer Claim Database assigned a data receiver claim control number of IC429888.

Harriett Mills’ (Member ID Number 6666666666) claim for $50.00 for date of service February 5, 2019 was accepted. The payer claim control number is 220216359807X. The All Payer Claim Database assigned a data receiver claim control number of IC429956.

X12 Syntax

ST*277*0003*005010X364~
BHT*0085*08*0000221*20190221*1025~
HL*1**20*1~
NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~
TRN*1*ABC12345~
DTP*050*D8*20190220~
DTP*009*D8*20190221~
HL*2*1*21*1~
NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~
TRN*2*206438976580901~
STC*DR02:20*20190221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~
HL*3*2*19*1~
NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~
HL*4*3*PT~
NM1*QC*1*PATIENT*FEMALE****MI*2222222222~
TRN*2*PATIENT22222~
STC*DR02:20:PR*20190221*WQ*100~
REF*F8*IC847502~
REF*1K*220216359803X~
DTP*472*D8*20190214~
HL*5*3*PT~
NM1*QC*1*PATIENT*MALE****MI*3333333333~
TRN*2*PATIENT33333~
STC*DR06:21*20190221*U*65******DR06:255~
REF*F8*IC429783~
REF*1K*220216359954X~
DTP*472*D8*20190121~
HL*6*3*PT~
NM1*QC*1*JONES*LARRY****MI*4444444444~
TRN*2*JONES44444~
STC*DR03:26:77*20190221*U*100~
REF*F8*IC429805~
REF*1K*220216359964X~
DTP*472*D8*20190211~
HL*7*2*19*1~
NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~
TRN*1*0~
REF*LU*AB142~
QTY*QA*2~
AMT*YU*100.5~
HL*8*7*PT~
NM1*QC*1*JOHNSON*MARY****MI*5555555555~
TRN*2*JOHNSON55555~
STC*DR08:20:PR*20190221*EZ*50.5~
REF*F8*IC429888~
REF*1K*220216359806X~
DTP*472*D8*20190210~
SVC*HC:G9938*50.5*****1~
STC*DR08:475**EZ~
REF*6R*1~
DTP*472*D8*20190210~
HL*9*7*PT~
NM1*QC*1*MILLS*HARRIETT****MI*6666666666~
TRN*2*MILLS66666~
STC*DR02:20:PR*20190221*WQ*50~
REF*F8*IC429956~
REF*1K*220216359807X~
DTP*472*D8*20190205~
SE*63*0003~

Source

x12.org/examples/005010×364 ; x12.org/examples/005010×364/example-1

X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.

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