Example 3: Claim Transferred to Another Entity For Processing

Business Scenario Description:
This scenario depicts an Information Source indicating in a 277 Health Care Claim Status Response to a 276 Health Care 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).

Judy Marie Robinson is the subscriber with a member identification number of G44456789 (Loop 2100D NM109). Judy’s birth date is 07/02/1985 (Loop 2000D DMG02). A Claim Status Trace Number of ABCXYZ1 (Loop 2200D TRN02) was assigned to the status request for Judy Robinson's claim. Home Hospital requested the status of a claim for inpatient services (Type of Bill 111, Loop 2200D REF01=BLT) for services October 31, 2025 through November 12, 2025 (Loop 2200D DTP01=472) in the amount of $13,200.76 (Loop 2200D AMT01=T3). Home Hospital provided a Provider’s Assigned Claim Identifier of RJ623872456 (Loop 2200D REF01=X1).

ABC Insurance accepted the 276 Health Care Claim Status Request for processing and determined that the claim had been transferred to Timbuktu Health Insurance, which is Judy’s primary health insurance, for processing. Based on this, the 277 Health Care Claim Status Response returned by ABC Insurance reported Claim Status Category Code A0 – “Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity.” (Loop 2200D STC01-01), Claim Status Code 16 – “Claim/encounter has been forwarded to entity. Usage: This code requires use of an Entity Code.” (Loop 2200D STC01-02), and Entity Code of PRP – “Primary Payer” (Loop 2200D STC01-03). Additionally, as required, reported Timbuktu Health Insurance as the Transfer to Entity Name (Loop 2210D N102), and their contact information (telephone number in Loop 2210D PER04 and their url in PER06). ABC Insurance was also able to provide the address for Timbuktu Health Insurance (Loop 2210D N3 and N4).