Example 9: Request Response Claim Number Search Claim Not Found

Business Scenario Description:
This scenario depicts a request and response for status where the Payer Claim Control Number was submitted on the request, but the payer did not find the requested claim and performed a secondary search using the other submitted data. (Reference: Section 1.4.8 - Payer Claim Control Number Search and Response)

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.

Home Hospital Physicians uses XYZ Service to submit claim status requests to ABC Insurance. Home Hospital Physicians National Provider Identifier (NPI) is 1666666661.

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 Physicians provided a Provider's Assigned Claim Identifier of SM123456, along with a charge of $100 and date of service September 15, 2025 on their request. A Payer Claim Control Number of 2020365123456 was also submitted for the specific claim for which they were inquiring.

ABC Insurance used the submitted Payer Claim Control Number for their initial claim search. ABC Insurance did not find a claim with the submitted claim number. As required by the guide, ABC Insurance responded they were unable to locate the claim based on that specific claim number (D0:464).

ABC Insurance performed a secondary search for claims using the other submitted data (charge, date of service, Provider's Assigned Claim Identifier, etc.) and found a claim that matched the other criteria. On the secondary search claim, ABC Insurance provided a status that the claim was denied because the service was not authorized (F2:84). ABC Insurance reported a Payer Claim Control Number of 2021365123456 for the claim found in the secondary search. This response uses the same TRN as submitted on the 276 so that the provider can link both responses to the request.