UHIN Standard #20 Claim/Encounter Acknowledgement
Origination Date: V.1: April 1998
Origination Date, V.2: July 2002
APPROVEDV.2
UHIN STANDARDS COMMITTEE
STANDARD # 20 - 4010
Claim/Encounter Acknowledgement
Version 2
UHIN Standard #20 Claim/Encounter Acknowledgement is compatible with all HIPAA requirements.
Purpose: The purpose of Standard #20 is to delineate a standardized front-end claim/encounter acknowledgement transaction. This transaction will be used only to report on the status of a claim/encounter at the level of the payers “front end” claim/encounter edits, i.e., before the payer is legally required to keep a history of the claim/encounter.
Applicability: This Standard applies to all claims/encounters acknowledgements to HIPAA X12 claim/encounter (837) transactions.
Details:
1.UHIN will implement the January 2001 DRAFT #10 004020 version of the ANSI ASC X12.N Unsolicited 277, Health Care Claim Status Notification – Front-End Acknowledgement transaction, known as the 277FE . This transaction will be available for downloading from the Utah Insurance Commissioners web site [ include site ] and from UHIN, - Standards.
2.Provider Responsibilities:
a.Providers are responsible for assigning a unique claim/encounter identifier (called the Patient Control Number, PCN) in the CLM01 of the 837 (Health Care Claim/Encounter) transaction. This number must be unique to each claim/encounter or providers will have difficulty identifying claims/encounters in the EDI status reports received from payers.
b.Providers must have software at their end to be able to receive and decipher the transaction.
3.Payer Responsibilities:
a.Payers will return the information in the Front-End Acknowledgement Status reports as shown below in “277 Mapping”:
b.Payers will use the Claim/Encounter Status codes for this transaction in the manner detailed in the attached code list. Other 277 codes will not be used in this application of the 277 transaction. If a payer adds new front-end edits which require additional 277 codes, it is their responsibility to alert a UHIN Standards Committee staff member to allow staff to convene the UHIN Codes Committee to review the new code(s) needed. If a payer needs a code that is not within the national code list, then it is the responsibility of the payer to apply for additional codes. Only official national codes may be used. See X12 Code Source 508 or go to all current Status codes
c.When a payer returns a status with the category code of “A2" (claim/encounter accepted for adjudication), the payer must also send their claim/encounter control number (Loop ID-2200, REF01=1K).
d.In cases where a trading partner (e.g., a repricer) is passing the claim/encounter onto the destination payer the code ”A0 - Acknowledgement/Forwarded” will be used when the claim/encounter is accepted by the trading partner. In these cases, the trading partner would utilize the batch mode response detailed in item (d) below, and would use codes ”A0" for claims/encounters which passed their ”front-end“ edits, or ”A3" for /encounters which were rejected. The trading partner does not return their claim/encounter identification number in A3 responses. No further response is necessary.
e.Category code ”A1 - Acknowledgment/Receipt” is used when a trading partner acknowledges the claim/encounter is accepted electronically but has not yet entered the adjudication system. In these cases, the trading partner would respond in a batch mode (see item 2.f.Batch Response Mode: below) and would use code”A1" for /encounters which have gone to be researched manually, or code”A3" for /encounters which were rejected. The payer claim/encounter control number may be returned on claims/encounters with the “A1" status but it is not required. When “A1" is used, the trading partner must still report (at a later time) to the provider when a claim/encounter is either accepted into their adjudication system (A2) or rejected (A3). However, it is permissible to implement this additional reporting in a second phase separate from the rest of the 277FE Standard. This second 277FE communication is done on a claim/encounter-by-claim/encounter basis rather than in batch mode; the 837 ICN (Interchange Control Number – ISA13) is not returned (enter “00” in 2200 TRN02 to indicate no 837 ICN). If a payer decides to use the “A1" option, it is permissible to implement it in a separate phase from the rest of the 277FE Standard.
Payers may use a non-electronic method of implementing the second phase until they are ready to implement the 277FE version.
f.Batch Response Mode:
When an 837 transaction (ST-SEtransaction) is initially received by a trading partner, the Front-End Acknowledgement Status reports must be returned on a batch-for-batch basis with Claim/Encounter (837) transactions if the original claim/encounter transaction was accepted in a valid format (i.e., 997 report shows acceptance of the functional group).
g.Payers are required to return the batch EDI-Claim/Encounter Status within 3 business days of receiving a Claim/Encounter (837) transaction.
h.Handling replacement claims/encounters.
A replacement claim/encounter is one which uses the value of “7” in CLM05-3.
Payers may reject replacement claims/encounters if the payer trace number is not included in the duplicate corrected claim/encounter (Loop ID-2300, REF01=G8), or if the payer trace number included in the replacement claim/encounter is incorrect (e.g., a payer claim/encounter number which was assigned to a different provider). See UHIN Standard #20 4010 - 277FE below for claim/encounter status codes to communicate these rejections.
- Handling duplicate claims/encounters
Payers may reject or accept duplicate claims/encounters during the ‘front end’ editing process. This is a business decision on the part of the claim/encounter receiver.
IMPLEMENTATION ISSUES
1.Educate providers about the use of this transaction.
2.Educate translator vendors about the use of this transaction.
3.Implementation Date: With 4010 Health Care Claim Implementation Schedules.
ORIGINATION DATE: April 6, 1998
BOARD APPROVAL DATE: October 13, 1998
EFFECTIVE DATE: November 13, 1998
V.2 BOARD APPROVAL DATE: September 9, 2002
EFFECTIVE DATE: October 9, 2002
G:\Jan\WPDOCS\Standards and Specs\A-Standards\To Board\20_277FE.doc 1
UHIN Standard #20 Claim/Encounter Acknowledgement
Origination Date: V.1: April 1998
Origination Date, V.2: July 2002
APPROVEDV.2
277FE MAPPING - All claim status codes (STC segments) originate with the INFORMATION SOURCE
DE#InformationLoop - ElementData4010 837Inst 4010 837Prof/Dent Element
1Test/Production IndicatorEnvelope - ISA15Indicates whether 277 is test or productionISA15ISA15
2ICN from originating 8372200A/B TRN02837 batch number H-BHT03H-BHT03
3Info. Source (Payer) Name2100A NM103Info Source Name1000B NM1031000B NM103
4 Info. Source ID number 2100A NM109Trading partner number1000B NM1091000B NM109
5Info. Receiver (Provider) Name2100B NM103Info Receiver Name1000A NM1031000A NM103
6Provider (Info Receiver) ID #2100B NM109Trading partner number1000A NM1091000A NM109
7Billing/Pay-to Provider Name2100C NM103Billing/Pay-to Provider Name2010AA/AB NM1032010AA/AB NM103
8Billing/Pay-to Provider ID #2100C NM109Billing/Pay-to Provider ID #2010AA/AB NM1092010AA/AB NM109
Billing/Pay-to Secondary ID #2100C REF01/02Billing/Pay-to Secondary ID #2010AA/AB REF01/022010AA/AB REF01/02
In cases where the subscriber is the same person as the patient, all information will be sent back as follows:
9Subscriber info - last name2010BA NM103Subscriber Last Name2010BA NM1032010BA NM103
10first name2010BA NM104Subscriber First Name2010BA NM1042010BA NM104
11middle name2010BA NM105Subscriber Middle Name (when present)2010BA NM1052010BA NM105
12Identifier2010BA NM109Subscriber Payer ID Number2010BA NM1092010BA NM109
13Provider unique claim/encounter #2200D TRN02Provider’s Claim control number2300 CLM012300 CLM01
14Total Claim/encounter Submitted Charges2200D STC04Total billed amount for claim/encounter2300 CLM022300 CLM02
15Medical Record Number (facility claims only)2200D REF04-2MRN 2300 REF02 (REF01=EA) NA
16Bill Type2200D REF02 (REF01=BLT)TOB2300 CLM05
17Policy or Group Number2200D REF02 (REF01=1L)Group or Policy Number2000B SBR032000B SBR03
18Date of Service2200D DTP03 (DTP01=232)Date of service 2300 DTP03 (434)Summarize from 2400 DTPs
Use the Line Level information (below) on an as-needed basis:
Line Control Number2200D REF02 (REF01=6R)Line control number2400 LX2400 REF02 (REF01=6R)
19Line - Procedure Code/Modifiers2220D SVC01Procedure code SVC01-1, -2, -3, -4, -5, or -6 2400 SV2032400 SV102/SV301
20Line - Billed Amount2200D SVC02Line billed charges2400 SV204SV103/SV302
21Line - Service Date2200D DTP03 (DTP01=472)Date of service 2400 DTP03 (DTP01=472) 2400 DTP03 (DTP01=472)
In cases where the patient is different than the subscriber information will be sent back as follows:
22Patient info - last name2010BA NM103Patient Last Name2010CA NM1032010CA NM103
23first name2010BA NM104Patient First Name2010CA NM1042010CA NM104
24middle name2010BA NM105Patient Middle Name (when present)2010CA NM1052010CA NM105
25Identifier2010BA NM109Patient identification number (if available)2010CA NM1092010CA NM109
13Provider unique claim/encounter #2200D TRN02Provider’s Claim control number2300 CLM012300 CLM01
14Total Claim/encounter Submitted Charges2200D STC04Total billed amount for claim/encounter2300 CLM022300 CLM02
15Medical Record Number (facility claims only)2200D REF04-2MRN 2300 REF02 (REF01=EA) NA
16Bill Type2200D REF02 (REF01=BLT)TOB2300 CLM05
17Policy or Group Number2200D REF02 (REF01=1L)Group or Policy Number2000B SBR032000B SBR03
18Date of Service2200D DTP03 (DTP01=232)Date of service 2300 DTP03 (434)Summarize from 2400 DTPs
Use the Line Level information (below) on an as-needed basis:
Line Control Number2200D REF02 (REF01=6R)Line control number2400 LX2400 REF02 (REF01=6R)
19Line - Procedure Code/Modifiers2220D SVC01Procedure code SVC01-1, -2, -3, -4, -5, or -6 2400 SV2032400 SV102/SV301
20Line - Billed Amount2200D SVC02Line billed charges2400 SV204SV103/SV302
21Line - Service Date2200D DTP03 (DTP01=472)Date of service 2400 DTP03 (DTP01=472) 2400 DTP03 (DTP01=472)
277 Front-End Acknowledgement Codes
julie/.../karla/standard/277/edi-codes/lst
Crosswalking payer edits to 277 codes is difficult to do consistently across different payers. Payer edits were developed in a paper environment this allowed for long sentences and paragraphs to convey information. Because of the paper environment, some edits were written to encompass many different concepts into a single edit. The 277 primarily contains codes rather than sentences. This is a profoundly different way to communicate. It is critical the receiver of the 277 codes be able to understand what is being communicated. Therefore, it is necessary the complex messages be broken into small understandable messages (“sentences”) with an identifiable “period” (end of the message). To achieve this, each STC segment is assumed to end in a “period.” This limits the sender to three STC codes (plus the optional use of STC12 for text) per “sentence.” If an edit contains more concepts than can be fitted into the STC structure, it is necessary to “rewrite” the edit into smaller “sentences” to allow for comprehensible coding.
Generic Edit / 277 code / 277 code in English / DiscussionAccepted
Claim/encounter accepted and forwarded to another entity / A0:16:PR
(other entity codes may be used) / Acknowledgement/Forwarded:Claim/encounter has been forwarded to entity:Payer / All claims /encounters which have been received by a trading partner who is not the destination payer (e.g. repricer). Use of this code indicates the claim/encounter passed the trading partners front end edits and will be fowarded on to the destination payer (although the claim/encounter may pass through other transmission intermediaries prior to reaching the destination payer). This code is sent at the claim/encounter level.
Claim/enconter accepted electronically; (no further status information is available at this time) / A1:19:PR
(other entity codes may be used) / Acknowledgement/Receipt:Entity acknowledges receipt of claim/encounter:payer / All claims/encounters which are accepted electronically but not into the adjudication system will have this code at the claim/encounter level. This code is used only by trading partners who are the destination payer. This code is sent at the claim/encounter level.
Claim/encounter accepted into adjudication system / A2:20 / Acknowledgement/Accepted: Accepted for processing. / All claims/encounters which are accepted into the destination payer’s adjudication system will have this code at the claim/encounter level.
Resubmitted claim/encounter accepted into EDI system. / A2:41 / Acknowledgement/Received: Special handling required at payer site. / Used to indicate a valid resubmitted claim/encounter has been received.
Rejected
Claim/encounter rejected / A3:____:___ / Acknowledgement/Rejected: see below for detail codes / All claims/encounters which are rejected will use this category code along with appropriate detail and/or entity code(s) (shown below). This code is sent at the claim/encounter or line level as appropriate.
Claim/encounter rejected for line level reasons (no claim/encounter level reasons) / A3: 122 / Acknowledgement/Rejected: Missing/invalid data prevents payer from processing claim/encounter. / Use this code as a place holder in the claim/encounter level STC01 when a claim/encounter has been rejected for line level reasons only.
Subscriber not found
missing/invalid name
missing/invalid ID # / A3:153:IL
A3:125:IL / Entitys ID #:Subscriber
Entitys name:Subscriber / This is an example of how the use of some 277 codes can be standardized. There are many entities who names, numbers, (etc) can be missing/invalid. Using this format allows providers to program as automated a response as possible.
Use the entity identifier to specify various types of providers, e.g., FA for facility or 82 for Rendering provider.
Dependent not found
missing/invalid name
missing/invalid ID # / A3:153:03
A3:125:03 / Entitys ID #:Dependent
Entitys name: Dependent
Provider not found
missing/invalid name
missing/invalid ID #
missing/invalid location / A3:125:1P
A3:153:1P
A3:126:1P / Entitys name:Provider
Entitys ID #:Provider
Entitys address:Provider
Diagnosis code missing/invalid / A3:255 / Diagnosis code
Member ineligible on DOS / A3:88:QC / Entity not eligible for benefits for submitted dates of service:patient
Provider not eligible (not on Plan/Panel) on DOS / A3:91:1P / Entity not eligible/not approved for dates of service:Provider / Use when provider is a non-participating provider
Invalid/missing claim/enconter/line date / A3:187 / Date(s) of service / Used for invalid/missing DOS, start/stop dates, cases where DOB is after DOS, etc. This code can be attached to a particular line or at the claim/encounter level to direct attention to the problem area(s) of the claim/encounter.
Claim/encounter/line charges are missing/invalid
Total amount billed / A3:178 / Submitted charges / This code would be used for any type of problem with claim/encounter amounts: if the total line amount does not equal the total submitted charges, if a $0.00 amount has been submitted incorrectly, if any submitted amount is incorrect. This code can be attached to a particular line or at the claim/encounter level to direct attention to the problem area(s) of the claim/encounter.
Provider not certified as an electronic submitter / A3:24:1P / Entity not approved as an electronic submitter:Provider
Duplicate claim/encounter found
Duplicate procedure found / A3:78 / Duplicate of an existing claim/encounter/line, awaiting processing. / Code 78 is used when the original claim/encounter is still in the adjudication process. If the original claim/encounter has been finally adjudicated, use code 54 instead.
A3:54 / Duplicate of a previously processed claim/encounter/line.
DRG code is invalid / A3:256 / DRG code(s)
Valid Authorization not found for member / A3:252 / Authorization/certification number
Unit(s) data is invalid / A3:258 / Days/units for procedure/revenue code.
Invalid procedure code / A3: 454 / Procedure code for service(s) rendered. / Use when procedure code is missing or invalid; example 1: if procedure code is incompatible with type of coverage (e.g., coverage is medical and proc code is dental); example 2: if proc code is not a valid code for that date (e.g. is no longer listed as a valid proc code).
Invalid revenue code / A3:455 / Revenue code for service(s) rendered. / Use when revenue code is missing or invalid; example 1: if revenue code is incompatible with type of coverage example 2: if revenue code is not a valid code for that date (e.g. is no longer listed as a valid revenue code).
Date of last menstrual period invalid/missing / A3:191 / Date of LMP
Date of onset invalid/missing / A3:397 / Date of onset of illness
Sex code invalid / A3:86 / Diagnosis and patient sex mismatch.
Claim/encounter submitted for medical benefits for which the subscriber is not eligible
Claim/encounter submitted for dental benefits for which the subscriber is not eligible
Claim/encounter submitted for ineligible benefits / A3:90:IL
A3:89:IL
A3:88:QC / Entity not eligible for medical benefits for submitted dates of service:subscriber
Entity not eligible for dental benefits for submitted dates of service:IL
Entity not eligible for benefits for submitted dates of service:patient
Missing/invalid tooth number
Missing/invalid “from” or “to” tooth number(s) / A3:243 / Tooth number or letter / Detail code 242 “Tooth numbers, surfaces, and/or quadrants involved” could be used, but it is probably best to use the minimal code. In this case, only tooth number is involved so it is recommended the 244 be used. In the case when only tooth surface is involved, it is recommended the240 “Tooth surface(s) involved.” If multiple data elements are involved (number, surface and/or quadrant), use 242.
Missing tooth surface / A3:240 / Tooth surface
Missing tooth number, surface and /or quadrants / A3:242 / Tooth numbers, surfaces, and/or
Quadrants
type of service is missing/invalid / A3:250 / Type of service
place of service is missing/invalid / A3:249 / Place of service
anesthesia minutes missing/invalid / A3:251 / Total anesthesia minutes
need text for whatever reason / A3:306 / Detailed description of procedure/service/supplies
date of banding/dental appliance placement / A3:203 / Date of dental appliance placed.
Band fee/monthly fee/class type / A3:246 / Total orthodontic service fee, initial appliance fee, monthly fee, length of service.
Problem with COB charges from a Prior payer / A3:286 / Other payer's Explanation of Benefits/payment information.
Wrong payer’s claim/encounter number / A3:162:1P / Entity’s health insurance claim/encounter number: Payer / Used to indicate the provider has submitted an incorrect payer claim/encounter number on a resubmitted/corrected claim/encounter.
Invalid/Missing Payer Claim Control Number / A3:162:PR / Entity’s health insurance claim number (HINC): Payer / The claim is probably a replacement claim. This payer requires that the provider include the payer’s claim control number on all replacement claims. The payer’s claim number is missing from the replacement claim.
Predetermination of benefits claims are not accepted / A3:484 / Business application currently not available. / This payer does not currently accept predetermination of benefits claims.
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