Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 277 | TR3 ID: 005010X214

Example 01 - Payer Response

Business Scenario Description
This scenario reflects a Payer response of an accepted file with some claims not accepted for processing.

Business Scenario Explanation
In the following example, Dr. Harry B. Jones (Electronic Transmitter ID Number S00003) submitted an 837 Professional claim file with inventory file number 2002022045678 in BHT03 directly to “Your Insurance Company” (Payer ID Number YIC01) on February 20, 2023, for himself (Tax ID Number 234567894). Your Insurance Company processed the file on February 21, 2023 and notified Dr. Jones that although the file containing five claims for charges totaling $365.50 was accepted, there were two individual claims not accepted for processing.

Following is the status information for the claims contained in the 837 claims transmission file:

  • Claim 1 - Female Patient’s (Member ID Number 2222222222) claim for $100.00 for date of service February 14, 2023, was accepted and an internal claim control number of 220216359803X was assigned to this claim.
  • Claim 2 - Male Patient’s (Member ID Number 3333333333) claim for $65.00 was rejected as unprocessable because the reported date of service, February 29, 2023, was invalid.
  • Claim 3 - Larry Jones’ (Member ID Number 4444444444) claim for $100.00 for date of service February 11, 2023, was rejected because the place of service was invalid.
  • Claim 4 - Mary Johnson’s (Member ID Number 5555555555) claim for $50.50 for date of service February 10, 2023, was accepted and an internal claim control number of 220216359806X was assigned to this claim.
  • Claim 5 - Harriett Miller’s (Member ID Number 6666666666) claim for $50.00 for date of service February 5, 2023, was accepted and an internal claim control number of 220216359807X was assigned to this claim.

Corresponding Business Scenario Transaction

HEADER

ST*277*0003*005010X214~
BHT*0085*08*277X2140003*20230221*1025*TH~

LOOP ID 2000A – INFORMATION SOURCE LEVEL

HL*1**20*1~

LOOP ID 2100A – INFORMATION SOURCE NAME

NM1*PR*2*YOUR INSURANCE COMPANY*****PI*YIC01~

LOOP ID 2200A – TRANSMISSION RECEIPT CONTROL IDENTIFIER

TRN*1*0091182~
DTP*050*D8*20230220~
DTP*009*D8*20230221~

LOOP ID 2000B – INFORMATION RECEIVER LEVEL

HL*2*1*21*1~

LOOP ID 2100B – INFORMATION RECEIVER NAME

NM1*41*1*JONES*HARRY*B***46*S00003~

LOOP ID 2200B – INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

TRN*2*2002022045678~
STC*A1:19:PR*20230221*WQ*365.5~
QTY*90*3~
QTY*AA*2~
AMT*YU*200.5~
AMT*YY*165~

LOOP ID 2000C – BILLING PROVIDER OF SERVICE LEVEL

HL*3*2*19*1~

LOOP ID 2100C – BILLING PROVIDER NAME

NM1*85*1*JONES*HARRY*B**MD*FI*234567894~

LOOP ID 2000D – PATIENT LEVEL (Claim 1)

HL*4*3*PT~

LOOP ID 2100D – PATIENT NAME

NM1*QC*1*PATIENT*FEMALE****MI*2222222222~

LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER

TRN*2*PATIENT22222~
STC*A2:20*20230221*WQ*100~
REF*1K*220216359803X~
DTP*472*D8*20230214~

LOOP ID 2000D – PATIENT LEVEL (Claim 2)

HL*5*3*PT~

LOOP ID 2100D – PATIENT NAME

NM1*QC*1*PATIENT*MALE****MI*3333333333~

LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER

TRN*2*PATIENT33333~
STC*A3:21*20230221*U*65******A3:187~
DTP*472*D8*20230229~

LOOP ID 2000D – PATIENT LEVEL (Claim 3)

HL*6*3*PT~

LOOP ID 2100D – PATIENT NAME

NM1*QC*1*JONES*LARRY****MI*4444444444~

LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER

TRN*2*JONES44444~
STC*A7:21*20230221*U*100******A7:249~
DTP*472*D8*20230211~

LOOP ID 2000D – PATIENT LEVEL (Claim 4)

HL*7*3*PT~

LOOP ID 2100D – PATIENT NAME

NM1*QC*1*JOHNSON*MARY****MI*5555555555~

LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER

TRN*2*JOHNSON55555~
STC*A2:20*20230221*WQ*50.5~
REF*1K*220216359806X~
DTP*472*D8*20230210~

LOOP ID 2000D – PATIENT LEVEL (Claim 5)

HL*8*3*PT~

LOOP ID 2100D – PATIENT NAME

NM1*QC*1*MILLER*HARRIETT****MI*6666666666~

LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER

TRN*2*MILLS66666~
STC*A2:20*20230221*WQ*50~
REF*1K*220216359807X~
DTP*472*D8*20230205~

TRANSACTION SET TRAILER

SE*46*0003~