Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 276/277 | TR3 ID: 005010X212

Example 1: Claim Level Status

ABC Insurance is both the Medicare Part A Fiscal Intermediary and a PPO. ABC insurance has a payer identification of 12345.

XYZ Service, which is a Clearinghouse, has an electronic transmitter identification number of X67E that it uses to conduct electronic business transactions with ABC Insurance.

Home Hospital and Home Hospital Physicians use XYZ Service to submit electronic claims and claim status requests to ABC Insurance. Home Hospital's National Provider Identifier (NPI) is 1666666661. Home Hospital Physicians' National Provider Identifier (NPI) is 1666666666.

The following details are for 3 claims that XYZ Service requested status and ABC Insurance responded:

Claim 1

Request: Fred Smith is a Medicare enrollee with a health insurance claim number of 123456789A. Mr. Smith's birth date is 12/10/1930. A claim status tracking number of ABCXYZ1 was assigned to the status inquiry for Mr. Smith's claim. Home Hospital requested the status of a claim for inpatient services (bill type 111) for services August 31, 2005 through September 6, 2005 in the amount of $8,513.88. Home Hospital provided a patient control number of SM123456.

Response: ABC Insurance assigned a payer claim control number of 05347006051 to Mr. Smith's claim. The claim was pending waiting on additional information that had already been requested.

Claim 2

Request: Mary Jones is a Medicare enrollee with a health insurance claim number of 234567890A. Mrs. Jones' birth date is 11/15/1930. A claim status tracking number of ABCXYZ2 was assigned to the status inquiry for Mrs. Jones' claim. Home Hospital requested the status of a claim for inpatient services (bill type 111) from July 31, 2005 through August 9, 2005 in the amount of $7,599.00. Home Hospital provided a patient control number of JO234567.

Response: ABC Insurance assigned a payer claim control number of 0529675341 to Mrs. Jones' claim. The claim completed adjudication and is awaiting the payment cycle.

Claim 3

Request: Joseph Mann is a dependent under John Mann's PPO plan. John Mann is the insured, or subscriber, and his member identification is 345678901. Joseph Mann's birth date is 11/01/1995. A claim status tracking number of ABCXYZ3 was assigned to the status inquiry for Joseph Mann's claim. Home Hospital Physicians requested the status of a service (99203) on May 1, 2005 in the amount of $150.00. Home Hospital Physicians provided a patient control number of MA345678.

Response: ABC Insurance assigned a payer internal control number of 051681010827 to Joseph Mann's claim.The service was denied because the dependent was not eligible for benefits at the time of service.