ASC X12 Version: 005010 | Transaction Set: 277 | TR3 ID: 005010X214
Example 02 - Payer Response Multiple Providers
Business Scenario Description
This scenario reflects a Payer response for a multiple provider file with some claims not accepted for processing.
Business Scenario Explanation
In the following example, Dr. Ewell B King (Electronic transmitter ID number S00005) submitted an 837 Professional claim file to “Our Insurance Company” (Payer ID Number OIC02) on March 20, 2023, for himself (NPI 5365432101) and Dr. Ivan Reed (NPI 1222334499). This file was transmitted after the cutoff time for same day processing, so, Our Insurance Company processed the file on March 21, 2023, notified a total of $455.00 was accepted, two of Dr King’s individual claims were not accepted for processing and all three of Dr. Reed’s claims were not accepted for processing as he had not completed the trading partner enrollment process to be an electronic submitter. Please note that the Corresponding Business Scenario 277 Health Care Claim Acknowledgment transaction reflects no additional hierarchical levels afterwards related to Dr. Reed’s claims (as per the Loop ID 2000C HL Billing Provider of Service Level Situational Rule).
Following is the status information for Dr. King’s the claims contained in the 837 claims transmission file:
- Claim 1 - Female Patient’s (Member ID Number 2222222222) claim for $55.00 for date of service March 14, 2023, was accepted and an internal claim control number of 22021635900803X was assigned to this claim.
- Claim 2 - Male Patient’s (Member ID Number 3333333333) claim for $50.00 was not accepted for processing because the date of service, February 29, 2023, was invalid.
- Claim 3 - Mary Jones’ (Member ID Number 4444444444) claim for $100.00 for date of service March 14, 2023, was not accepted for processing because the claim was submitted to the wrong payer.
- Claim 4 - Jimmy Johnson’s (Member ID Number 5555555555) claim for $50.00 for date of service March 10, 2023, was accepted and an internal claim control number of 2202163599926X was assigned to this claim.
- Claim 5 - Harley Milson’s (Member ID Number 6666666666) claim for $50.00 for date of service March 5, 2023, was accepted and an internal claim control number of 2202163599943X was assigned to this claim.
All 3 of Dr. Reed’s claims totaling $150.00 were rejected because the Billing Provider (Dr. Reed) is not approved as an electronic submitter.
Corresponding Business Scenario Transaction
HEADER
ST*277*0004*005010X214~
BHT*0085*08*277X2140004*20230321*1025*TH~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – INFORMATION SOURCE NAME
NM1*PR*2*OUR INSURANCE COMPANY*****PI*OIC02~
LOOP ID 2200A – TRANSMISSION RECEIPT CONTROL IDENTIFIER
TRN*1*00911232~
DTP*050*D8*20230320~
DTP*009*D8*20230321~
LOOP ID 2000B – INFORMATION RECEIVER LEVEL
HL*2*1*21*1~
LOOP ID 2100B – INFORMATION RECEIVER NAME
NM1*41*1*KING*EWELL*B***46*S00005~
LOOP ID 2200B – INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
TRN*2*200203207890~
STC*A1:19:PR*20230321*WQ*455~
QTY*90*3~
QTY*AA*5~
AMT*YU*155~
AMT*YY*300~
LOOP ID 2000C – BILLING PROVIDER OF SERVICE LEVEL
HL*3*2*19*1~
LOOP ID 2100C – BILLING PROVIDER NAME
NM1*85*1*KING*EWELL*B**MD*XX*5365432101~
LOOP ID 2200C – PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER
TRN*1*00098765432~
STC*A1:19:PR**WQ*305~
QTY*QA*3~
QTY*QC*2~
AMT*YU*155~
AMT*YY*150~
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*20230321*WQ*55~
REF*1K*22021635900803X~
DTP*472*D8*20230314~
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*20230321*U*50******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*MARY****MI*4444444444~
LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER
TRN*2*JONES44444~
STC*A3:116*20230321*U*100~
DTP*472*D8*20230314~
LOOP ID 2000D – PATIENT LEVEL (Claim 4)
HL*7*3*PT~
LOOP ID 2100D – PATIENT NAME
NM1*QC*1*JOHNSON*JIMMY****MI*5555555555~
LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER
TRN*2*JOHNSON55555~
STC*A2:20*20230321*WQ*50~
REF*1K*2202163599926X~
DTP*472*D8*20230310~
LOOP ID 2000D – PATIENT LEVEL (Claim 5)
HL*8*3*PT~
LOOP ID 2100D – PATIENT NAME
NM1*QC*1*MILSON*HARLEY****MI*6666666666~
LOOP ID 2200D – CLAIM STATUS TRACKING NUMBER
TRN*2*MILSO66666~
STC*A2:20*20230321*WQ*50~
REF*1K*2202163599943X~
DTP*472*D8*20230305~
LOOP ID 2000C – BILLING PROVIDER OF SERVICE LEVEL
HL*9*2*19*0~
LOOP ID 2100C – BILLING PROVIDER NAME
NM1*85*1*REED*IVAN***MD*XX*1222334499~
LOOP ID 2200C – PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER
TRN*1*00023456789~
STC*A3:24:85*20230321*U*150~
QTY*QC*3~
AMT*YY*150~
TRANSACTION SET TRAILER
SE*58*0004~