X12 Version: 008060 | Transaction Set: 276/277 | TR3 ID: 008060X329
Example 8: Provider Level Rejection at Member Level
Business Scenario Description:
Rejected due to Provider rejection. Rejection must be reported at the member level.
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.
Home Hospital uses XYZ Service to submit electronic claims and claim status requests to ABC Insurance. Home Hospital's National Provider Identifier (NPI) is 1666666661. However, the NPI was entered incorrectly as 1666666662 on the claim status request.
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 ABCXYZ1 was assigned to the status request for Fred Smith's claim. Home Hospital requested the status of a claim for inpatient services (Bill Type 111) for services August 31, 2025 through September 6, 2025 in the amount of $7,800. Home Hospital provided a Provider's Assigned Claim Identifier of SM123456.
ABC Insurance rejected the request due to the invalid NPI submitted in the service provider level loop (E0:26:1P). The response must be provided for each member at the claim-level loop.
Corresponding Business Scenario Transaction
276 Request
HEADER
ST*276*0002*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 – SERVICE PROVIDER NAME
NM1*1P*2*HOME HOSPITAL*****XX*1666666662~
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*123456789~
LOOP ID 2200D – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ1~
REF*BLT*111~
REF*X1*SM123456~
AMT*T3*7800~
DTP*472*RD8*20250831-20250906~
TRANSACTION SET TRAILER
SE*17*0002~
277 Response
HEADER
ST*277*0001*008060X329~
BHT*0085*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*HOME HOSPITAL*****XX*1666666662~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*0~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*123456789~
LOOP ID 2200D – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ1~
STC*E0:26:1P*20250925~
REF*X1*SM123456~
DTP*472*RD8*20250831-20250906~
TRANSACTION SET TRAILER
SE*16*0001~