Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 276/277 | TR3 ID: 005010X212

Example 2b: 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 3.2 - Business Scenario 2 -- Provider 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*2*19*0~

NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~

TRN*1*0~

STC*E0:24:1P*20050916~

SE*21*0001~