Example 10: Request Response Status Messaging for Subscriber Direct Paid Claims

Business Scenario Description:
This scenario depicts a request and response for status on a claim/service where the subscriber was paid directly rather than the provider. (Reference: Section 1.4.4.3 Status Messaging for Subscriber Direct Paid Claims/Services).

Business Scenario Explanation:
ABC Insurance, which is the Information Source, has a payer identification of 12345.

XYZ Service has an electronic transmitter identification number of X67E, which it uses to conduct electronic business transactions with ABC Insurance. XYZ Service submitted a claim status request on September 25, 2025 for a claim that was previously sent to ABC Insurance.

OON Physicians uses XYZ Service to submit claim status requests to ABC Insurance. OON Physicians' National Provider Identifier (NPI) is 1666666663. OON Physicians is not a contracting provider with ABC Insurance.

Fred Smith is the Insured with an identification number of 123456789. Fred Smith's birth date is 12/10/1960. A Claim Status Trace Number of OONP12345 was assigned to the status request for Fred Smith's claim that was previously submitted. OON Physicians provided a Provider's Assigned Claim Identifier of FRSM123456, along with a charge of $100 and date of service September 15, 2025 on their request.

ABC Insurance's policy is to make payment directly to the subscriber when the provider is non-contracting or non-participating with their networks. As a result, ABC Insurance provided the following claim status for Payer Claim Control Number 2025111123456. They advised the provider no payment will be made to him and any balance due must come from the subscriber (F4:6). They reported the claim was received on 09/17/2025, the total charge was $100.00 (STC04), the paid amount was 0 (STC05) and that the claim finalized processing on September 22, 2025 (STC06).