Section title: Requests for Interpretation
RFI #
2390
277-003070X070 2220D/SV03
Description

On the 277 version 003070X070, Loop 2220/SV03 element is required. The description reads 'Must equal zero' and 'This is the amount paid'. The amount paid is not always zero. Can this element be used for a different amount other than zero?

Response

This issue is explicitly addressed in the 277 version 003070X070. Section 1.3 Business Usage, states ‘This implementation guide will only address usage of the 277 as an unsolicited Health Care claim status notification. This business usage performs two functions. First, it acts as an application level acknowledgment of claims received. Second, it is used as an unsolicited listing of claims pending adjudication in a payer’s system.’

Use of the 2220D/E Loop is Situational. Based on the SVC notes, when the transaction is being used as a claim application acknowledgement, the 2220 loop is only used when the reason for the rejected claim (i.e. not paid) is at the service line level. When the transaction is being used for providing a list of pending claims (i.e. those claims and all the service lines are not finalized for payment), the guide notes indicate use of the service line data is not advised.

The Loop 2220D/E, SVC03 element is defined by the Semantic Note as the amount paid for the service. While the element usage is set to Required, the element note explicitly states the amount to be reported ‘Must equal zero’.

Based on the 2 business functions supported by the guide and the usage notes for Loop 2220 and the SVC03 element, the claims/services reported in the 277 would not have paid amounts; therefore reflecting a paid service amount greater than zero would not be applicable or consistent with the requirements of the guide and its defined functionality.

RFI Recommendation

In more current versions (005010 and beyond), these business functions are performed and represented in two separate guides. In both of the guides referenced below, the 2220 SVC03 element was made Not Used, since a paid amount is not applicable to the business functionality of the guides.
005010X214 – 277 Health Care Claim Acknowledgment
005010X228 – 277 Health Care Claim Pending Status Information

DOCUMENT ID
003070X070