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EDI 276-A1 Format Example

EDI 276-A1 Health Care Claim Status Request


The EDI 276-A1 transaction set is used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a healthcare payer.

Note: EDI 276-A1 does not replace the EDI 837 Health Care Claim transaction set but is intended for use after the receipt of a claim or encounter information. Such a request may occur at the summary or service line detail level.

EDI 276-A1 Transaction Loaded Into Healthcare Data Mapping Software

 

EDI 276-A1 Format Example
276 Request Transmission

ASC X12 Version: 005010 | Transaction Set: 276/277 | TR3 ID: 005010X212

The following is a 276 transmission XYZ Services sent to ABC Insurance requesting the status of a set of claims.

Transmission Explanation

ST*276*0001*005010X212~
BHT*0010*13*ABC276XXX*20050915*1425~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE*****PI*12345~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICE*****46*X67E~
HL*3*2*19*1~
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
HL*4*3*22*0~
DMG*D8*19301210*M~
NM1*IL*1*SMITH*FRED****MI*123456789A~
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*EJ*SM123456~
AMT*T3*8513.88~
DTP*472*RD8*20050831-20050906~
HL*5*3*22*0~
DMG*D8*19301115*F~
NM1*IL*1*JONES*MARY****MI*234567890A~
TRN*1*ABCXYZ2~
REF*BLT*111~
REF*EJ*JO234567~
AMT*T3*7599~
DTP*472*RD8*20050731-20050809~
HL*6*2*19*1~
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~
HL*7*6*22*1~
NM1*IL*1*MANN*JOHN****MI*345678901~
HL*8*7*23~
DMG*D8*19951101*M~
NM1*QC*1*MANN*JOSEPH~
TRN*1*ABCXYZ3~
REF*EJ*MA345678~
SVC*HC:99203*150*****1~
DTP*472*D8*20050501~
SE*36*0001~

Source

Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples

HL7 is the registered trademark of Health Level Seven International. 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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