ASC X12 Version: 008030 | Transaction Set: 276/277 | TR3 ID: 008030X329
Example 3: Claim Transferred to Another Entity For Processing
Business Scenario Description:
This scenario depicts an Information Source indicating in a 277 Claim Status Response to a 276 Claim Status Request that the claim had been transferred to another entity for processing.
Business Scenario Explanation:
XYZ Service, a Clearinghouse, has an electronic transmitter identification number of X67E (Loop 2100B NM109) which it uses to conduct electronic business transactions with ABC Insurance. ABC Insurance has a payer identification of 12345 (Loop 2100A NM109). XYZ Service assigned their own unique Claim Identifier for Transmission Intermediaries number of XYZSMITH123 for tracking purposes (Loop 2200D REF01 = D9).
Home Hospital uses XYZ Service to submit claim status requests to ABC Insurance. Home Hospital's National Provider Identifier (NPI) is 1666666661 (Loop 2100C NM109).
Fred Smith is the subscriber with a member identification number of 123456789 (Loop 2100D NM109). Fred Smith's birth date is 12/10/1980 (Loop 2000D DMG02). A Claim Status Trace Number of ABCXYZ1 (Loop 2200D TRN02) was assigned to the status request for Fred Smith's claim. Home Hospital requested the status of a claim for inpatient services (Type of Bill 111, Loop 2200D REF01=BLT) for services August 31, 2025 through September 6, 2025 (Loop 2200D DTP01=472) in the amount of $8,513.88 (Loop 2200D AMT01=T3). Home Hospital provided a Provider’s Assigned Claim Identifier of SM123456 (Loop 2200D REF01=X1).
ABC Insurance was unable to respond to the specific claim status request due to system availability. ABC Insurance responded at the Information Receiver Level indicating a response was not possible (Loop 2200B STC01-01= E1- Response not possible - System Status) because the system was currently unavailable (Loop 2200B STC01-02= 484- Business Application Currently Not Available) and identified the entity as the payer (Loop 2200B STC01-03= PR – Payer).
Corresponding Business Scenario Transaction
276 Request
HEADER
ST*276*0001*008030X329~
BHT*0010*13*00009765*20250925*1200~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – PAYER NAME
NM1*PR*2*ABC INSURANCE*****PI*12345~
LOOP ID 2000B – INFORMATION RECEIVER LEVEL
HL*2*1*21*1~
LOOP ID 2100B – INFORMATION RECEIVER NAME
NM1*41*2*XYZ SERVICE*****46*X67E~
LOOP ID 2000C – SERVICE PROVDER LEVEL
HL*3*2*19*1~
LOOP ID 2100C – PROVIDER NAME
NM1*1P*2*HOME HOSPITAL*****XX*1666666661~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*0~
DMG*D8*19801210*M~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*123456789~
LOOP ID 2200D – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*X1*SM123456~
REF*D9*XYZSMITH123~
AMT*T3*8513.88~
DTP*472*RD8*20250831-20250906~
TRANSACTION SET TRAILER
SE*18*0001~
277 Response
HEADER
ST*277*0002*008030X329~
BHT*0010*08*00009765*20250925*1200*DG~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – PAYER NAME
NM1*PR*2*ABC INSURANCE*****PI*12345~
LOOP ID 2000B – INFORMATION RECEIVER LEVEL
HL*2*1*21*1~
LOOP ID 2100B – INFORMATION RECEIVER NAME
NM1*41*2*XYZ SERVICE*****46*X67E~
LOOP ID 2200B – INFORMATION RECEIVER TRACE IDENTIFIER
TRN*2*00009765~
STC*E1:484:PR*20250925~
TRANSACTION SET TRAILER
SE*9*0002~