X12 Version: 008060 | Transaction Set: 276/277 | TR3 ID: 008060X329
Example 4: Dental Claim Level Request and Response - Insured
Business Scenario Description:
Claim Level Request and Response – Dental Claim
Business Scenario Explanation:
ABC Insurance, which is the Information Source (Loop 2100A NM1), has a payer identification of 12345.
XYZ Service has an electronic transmitter identification number of X67E (Loop 2100B NM109), which it uses to conduct electronic business transactions with ABC Insurance.
Dental Physician uses XYZ Service to submit electronic health care claims and Health Care Claim Status Requests (276) to ABC Insurance (Loop 2100C NM1). Dental Physician’s National Provider Identifier (NPI) is 1666666667.
Fred Smith is the Subscriber/Insured with an identification number of AAA123456789 (Loop 2100D NM109). Fred Smith's birth date is 12/10/1960 (Loop 2000D DMG). A Claim Status Trace Number of ABCXYZ1 (Loop 2200D TRN02) was assigned to the status request for Fred Smith's claim. Dental Physician requested the status of a service, procedure code D2150 (Loop 2210D SVC) and 2 surfaces M and O (Loop 2210D TOO).
Total Claim Charge Amount of $150.00 and included a Provider’s Assigned Claim Identifier of SD123456 (Loop 2200D REF01 = X1).
ABC Insurance located the specific claim and returned the corresponding Health Care Claim Status Response (277). The claim was received on September 10, 2025 (Loop 2200D DTP01 = 050) and it was assigned a Payer Claim Control Number of 05347006051 (Loop 2200D REF01 = 1K).
As a result, the 277 Health Care Claim Status Response reported Claim Status Category Code F2-“Finalized/Denial-The claim/line has been denied.” (Loop 2220D STC01-01) and Claim Status Code 54-“Duplicate of a previously processed claim/line.” (Loop 2220D STC01-02).
Corresponding Business Scenario Transaction
276 Request
HEADER
ST*276*0001*008060X329~
BHT*0010*13*00009765*20250925*1330~
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*DENTAL PHYSICIAN*****XX*1666666667~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*0~
DMG*D8*19601210*M~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*AAA123456789~
LOOP ID 2200D – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ1~
REF*X1*SD123456~
AMT*T3*150~
DTP*472*D8*20250906~
LOOP ID 2210D – SERVICE LINE INFORMATION
SVC*AD^D2150*150*****1~
DTP*472*D8*20250906~
TOO*JP*12*M^O~
TRANSACTION SET TRAILER
SE*19*0001~
277 Response
HEADER
ST*277*1112*008060X329~
BHT*0010*08*00009765*20250925*1330*DG~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – PAYER NAME
NM1*PR*2*ABC INSURANCE*****PI*12345~
PER*IC**TE*3135551234~
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*DENTAL PHYSICIAN*****XX*1666666667~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*0~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*AAA123456789~
LOOP ID 2200D – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ1~
STC*F2^54*20250924**150~
REF*1K*05347006051~
REF*X1*SD123456~
DTP*472*D8*20250906~
DTP*050*RD8*20250910~
LOOP ID 2220D – SERVICE LINE INFORMATION
SVC*AD^D2150*150*0****1~
STC*F2^54*20250924**150~
DTP*472*D8*20250906~
TOO*JP*12*M^O~
TRANSACTION SET TRAILER
SE*22*1112~