Section title: Requests for Interpretation
RFI #
2328
276 REF*1K / 277 STC
Description

A payer is not returning any STC segment in the 277 Claim Status Response due to the 276 Claim Status Request not supplying the ICN in Loop 2200D, Segment REF (1K Qualifier).
1.Isn’t the payer required to send a STC segment in the 277 at least at in Loop 2200B in order to send a compliant transaction, regardless of their 276 requirement?
2.The 276 situational rule for Segment REF-Payer Claim Control Number (Qualifier 1K) in the 276 reads “Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.” This payer does not supply an ICN electronically on a claim ack report, therefore the Provider would not know the payer assigned number without calling the Payer first to which they could verbally acquire claim status making the 276/277 process not needed. Can a payer require the REF 1K in the 276 if they don’t electronically supply the ICN to the provider to begin with?

Response

The 005010X212 - 277 Response requires an STC segment (status message)  be reported at the most appropriate level of the transaction.  An STC segment is required at the 2200B when rejecting the request at the Information Source or Information Receiver level.  An STC segment is required at the 2200C when rejecting the request/inquiry at the provider level.  An STC segment is required at the 2200D (Subscriber) or 2200E (Dependent) when responding at the Subscriber or Dependent level and the previous STC segments (2200B or 2200C) have not been returned.
The 005010X212 - 276 Request 2200D/E REF-Payer Claim Control Number is a Situational element with a usage rule that states: 'Required when the Information Receiver knows the payer assigned number and intends the search criteria be narrowed to a specific claim. If not required by this implementation guide, do not send.' Based on the segment rule, submission of the Payer Claim Control Number is entirely at the discretion of the 276 submitter (provider). The payer cannot require the Payer Claim Control Number be submitted on the 276 Claims Status Inquiry Transaction.
Even if the payer does supply the Payer Claim Control Number on a 277 Claim Acknowledgement or some other type of proprietary acknowledgement, the provider is not required to send that number in the 276. The 276/277 allows the provider to submit 'open-ended' requests for a specific Subscriber or Dependent using varying pieces of data, including a service date range. The provider decides when they want the payer to narrow the request to a specific claim by sending the Payer Claim Control Number as part of their request information.

DOCUMENT ID
005010X212