Section title: Requests for Interpretation
RFI #
2589
Appropriate reporting of Pending Status Codes 276/277
Description

Guidance is needed on appropriate reporting of multiple Pending status codes being reported on the 277 transaction from a Payer on the same claim.  Is it compliant with the 276/277 Companion Guide to reply with the same TRN03 Multiple times with different STC Pending status codes?

Scenario

Example:

2000A HL*1**20*1~

            NM1*PR*2*PAYER NAME*****PI*12345~

2000B HL*2*1*21*1~

            NM1*41*2*PROVIDER NAME*****46*1234567890~

2000C HL*3*2*19*1~

            NM1*1P*2*PROVIDER NAME*****XX*1234567890~

2000D HL*4*3*22*1~

            NM1*IL*1*LAST*FIRST****MI*123456789~

2000E  HL*5*4*23~

            NM1*QC*1*LAST*FIRST~

            TRN*2*99999-999~

2200E  STC*P3:123:1P*20220817**55555.55~

            REF*1K*LLNNNNNNN~

            REF*BLT*131~

            REF*EJ*111111111111111~

            DTP*472*D8*20220928~

            SVC*HC:27792:RT*10109*0*0360***1~

            STC*P4:52*20220817~

            REF*FJ*2~

            DTP*472*D8*20220928~

            SVC*HC:64445:XP:RT*739*0*0360***1~

            STC*P4:52*20220817~

            REF*FJ*3~

            DTP*472*D8*20220928~

            SVC*HC:C1713*529.55*0*0278***1~

            STC*P4:52*20220817~

            REF*FJ*4~

            DTP*472*D8*20220928~

            TRN*2*99999-999~

            STC*P2:0*20220819**55555.55~

            REF*1K*DM23221573~

            REF*BLT*131~

            REF*EJ*111111111111111~

            DTP*472*D8*20220928~

            SVC*HC:27792:RT*10109*0*0360***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111111~

            DTP*472*D8*20220928~

            SVC*HC:64445:XP:RT*739*0*0360***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111112~

            DTP*472*D8*20220928~

            SVC*HC:C1713*78*0*0278***1~

            STC*P1:20*20220819~

            REF*FJ*11111111111111110~

            DTP*472*D8*20220928~

            SVC*HC:J0690*8*0*0636***4~

            STC*P1:20*20220819~

            REF*FJ*1111111111111112~

            DTP*472*D8*20220928~

            SVC*HC:J1100*2.54*0*0636***10~

            STC*P1:20*20220819~

            REF*FJ*1111111111111114~

            DTP*472*D8*20220928~

            SVC*HC:J1170*3.96*0*0636***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111118~

            DTP*472*D8*20220928~

            SVC*HC:J2250*2.82*0*0636***2~

            STC*P1:20*20220819~

            REF*FJ*1111111111111115~

            DTP*472*D8*20220928~

            SVC*HC:73600:RT*263*0*0320***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111113~

            DTP*472*D8*20220928~

            SVC*HC:77071*165*0*0320***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111114~

            DTP*472*D8*20220928~

            SVC*HC:J3010*1.23*0*0636***2~

            STC*P1:20*20220819~

            REF*FJ*1111111111111113~

            DTP*472*D8*20220928~

            SVC*HC:J7120*5*0*0636***1~

            STC*P1:20*20220819~

            REF*FJ*1111111111111116~

               DTP*472*D8*20220928~

RFI Response

A review of the provided Business Scenario example and the Health Care Claim Status Request and Response 276/277 (X12N/05010X212) TR3 concludes the Business Scenario example with the same TRN02 reported two times, each with different STC Pending status codes is permitted. 

This is supported by the following:

  • Section 1.3.2.1 Real Time and Batch Transmissions states both batch and real time permit the Health Care Claim Status 277 Response to return multiple responses to a single Health Care Claim Status 276 Request depending on the specificity of the request criteria and the payer's system capabilities.  It also indicates “Date search criteria may vary by payer.  This includes date ranges or available history.”
  • The Business Scenario example of a Health Care Claim Status 277 Response reflects what appears to be two independent pended claim responses. 
    • Each Loop 2200E reflects a unique (different) Payer Claim Control Number (Loop 2200E REF*1K) which is assigned by the payer and is internal to their system; the X12N/05010X212 guide does not address how a payer assigns their unique Payer Claim Control Number.
    • Loop 2200E supports a Loop repeat of >1 and the provided Business Scenario example has two repeats of Loop 2200E.

Note: Loop 2200E begins at the TRN segment and not at the STC segment as reflected in the provided Business Scenario example.

    • A different Status Information Effective Date (STC02) is reported for each Loop 2200E and its corresponding Loop 2220E.

Note: The example reflects a date of service (Loop 2220E DTP*472 with DTP03 = 20220928) which is greater than the Status Effective Date (Loop 2200E and 2220E STC02 = 20220817 or 20220819).  We assumed this was a typo/oversight in creating the provided example. 

  • The Health Care Claim Status Request and Response 276/277 (X12N/05010X212) is a paired transaction.  It requires reassociation of the 277 Response to the original 276 Request.  Reassociation is accomplished via the Referenced Transaction Trace Number (TRN02).  This number is assigned by the originator of the Health Care Claim Status 276 Request (Information Receiver) and must be returned in the Health Care Claim Status 277 Response (refer to Section 1.4.2.1 The Claim) to ensure reassociation.  We assume the Health Care Claim Status 276 Request contained the same TRN02 value and therefore the reassociation requirement is being met with each pended status reported (i.e., repeat of Loop 2200E).
  • Additionally, each Loop 2200E reflects the same Patient Control Number (REF*EJ) as required; here, too, we assumed this is the same Patient Control Number reported in the corresponding Health Care Claim Status 276 Request.

One additional note is regarding the Loop 2220E REF Service Line Item Identification (REF*FJ) reflected in the Business Scenario example.  We noted the structure of the data reported as a Line Item Control Number (Loop 2220E REF02) differs in each repeat of Loop 2200E (e.g., REF*FJ*2~ versus REF*FJ*1111111111111111~).  While we are unable to determine which reported Line Item Control Number is accurate, we can state the reported Line Item Control Number should be the same value reported on the original claim.  Also, the Loop 2220E REF Service Line Item Identification Situational Rule states “Required when the Service Line Item Identification was submitted on the 276 Request and service level status is reported.  If not required by this implementation guide, do not send.” Without the corresponding Health Care Claim Status 276 Request, we are unable to determine if Loop 2210E REF Service Line Item Identification segment was included, thereby requiring the Health Care Claim Status 277 Response to include the Line Item Control Number (as per the Situational Rule).

RFI Recommendation

Section 1.4 Business Usage of the 276/277 TR3 does state “The payer uses the 277 to transmit the current system status of those requested claims.  Claim history parameters may vary by payers and systems.”  Even though there are two different Payer Claim Control Numbers for what appears to be the same claim, to avoid confusion the payer should only report the most current system (pended) status (Loop 2200E with STC02 = 20220819). 

Please note this recommendation only applies when they are the same instance of a claim in the Information Source’s system.  Reporting multiple claims is appropriate when there are multiple claims within the Information Source’s system (e.g., duplicate claim, corrected claim, Etc.). 

 

Related RFIs: 1382

DOCUMENT ID
005010X212