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EDI 277-A3 Format Example

EDI 277-A3 Health Care Claim Status Response


The EDI 277-A3 transaction is an acknowledgment returned as an unprocessable claim. The claim or encounter has been rejected and has not been entered into the adjudication system.

Note: The EDI 277 transaction set has been specified by HIPAA for the submission of claim status information to respond to a previously received EDI 276 Claim Status Inquiry, to request that a payer provide additional information about a submitted claim (no 276 involved), or for a payer to provide claim status information to a provider via the EDI 277, without having received a 276.

EDI 277-A3 Transaction Example in Healthcare Data Mapping Software

 

EDI 277-A Format Example
Claim Level Status with NCPDP Reject/Payment Code

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

ABC Insurance is a Medicaid Fiscal Agent. ABC Insurance has a payer identification of 12345.
XYZ Service, which is a Clearinghouse, has an electronic transmitter identification number of X67E which it uses to conduct electronic business transactions with ABC Insurance.
Home Hospital Pharmacy uses XYZ Service to submit electronic claims and claim status requests to ABC Insurance. Home Hospital Pharmacy’s National Provider Identifier (NPI) is 1666666662.

The following details are for 1 claim that XYZ Service requested status and ABC Insurance responded:

Claim 1

Request: Fred Smith is a Medicaid enrollee with a Medicaid subscriber identification of 123456789012. Mr. Smith’s birth date is 12/10/1930. A claim status tracking number of ABCXYZ1 was assigned to the status inquiry for Mr. Smith’s claim. Home Hospital Pharmacy requested the status of a claim for a pharmacy service on March 1, 2006, in the amount of $85. Home Hospital Pharmacy provided a pharmacy prescription number of 7654321.

Response: ABC Insurance assigned a payer claim control number of 05347006051. ABC Insurance provided status using a Claim Status Category of F2 (Finalized/Denied) and a National Council for Prescription Drug Programs (NCPDP) Reject/Payment Code of 80 (Drug- diagnosis mismatch) to indicated the denial reason. The NCPDP Status Code Source was identified by the use of the RX Code Source Qualifier in STC01-4.

277 ResponseTransmission

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

The following is the 277 transmission ABC Insurance sent in response to the 276 transmissions from XYZ Service regarding the pharmacy claim status.

Transmission Explanation

ST*277*0001*005010X212~
BHT*0010*08*277X212*20060415*0810*DG~
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 PHARMACY*****XX*1666666662~
HL*4*3*22*0~
NM1*IL*1*SMITH*FRED****MI*123456789012~
TRN*2*ABCXYZ1~
STC*F2:80::RX*20060301**85*0~
REF*1K*05347006051~
REF*XZ*7654321~
DTP*472*D8*20060301~
SE*16*0001~

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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