Section title: X12 EDI Examples
back to previous

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

Example 1b: 277 Response Transmission

The following is the 277 transmission ABC Insurance sent in response to the 276 transmission from XYZ Service regarding the claims described in Section 3.1 - Business Scenario 1 -- Claim Level Status.

Transmission

ST*277*0001*005010X212~

BHT*0010*08*277X212*20050916*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*****XX*1666666661~

HL*4*3*22*0~

NM1*IL*1*SMITH*FRED****MI*123456789A~

TRN*2*ABCXYZ1~

STC*P3:317*20050913**8513.88~

REF*1K*05347006051~

REF*BLT*111~

REF*EJ*SM123456~

DTP*472*RD8*20050831-20050906~

HL*5*3*22*0~

NM1*IL*1*JONES*MARY****MI*234567890A~

TRN*2*ABCXYZ2~

STC*F0:3*20050915**7599*7599~

REF*1K*0529675341~

REF*BLT*111~

REF*EJ*JO234567~

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~

NM1*QC*1*MANN*JOSEPH~

TRN*2*ABCXYC3~

STC*F2:88:QC*20050612**150*0~

REF*1K*051681010827~

REF*EJ*MA345678~

SVC*HC:99203*150*0****1~

STC*F2:88:QC*20050612~

DTP*472*D8*20050501~

SE*38*0001~