276

Health Care Claim Status Request

Functional Group=HR

This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Claim Status Request Transaction Set (276) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used by a provider, recipient of health care products or services, or their authorized agent to request the status of a health care claim or encounter from a health care payer. This transaction set is not intended to replace the Health Care Claim Transaction Set (837), but rather to occur after the receipt of a claim or encounter information. The request may occur at the summary or service line detail level.

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	ISA	Interchange Control Header	M	1			Required
	GS	Functional Group Header	M	1			Required

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
010	ST	Transaction Set Header	M	1			Required
020	BHT	Beginning of Hierarchical Transaction	M	1			Required

	Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
LOOP ID - 2000A						>1
	010	HL	Information Source Level	M	1			Required
LOOP ID - 2100A						>1
	050	NM1	Payer Name	O	1			Required
	080	PER	Payer Contact Information	O	1			Situational

LOOP ID - 2000B						>1
	010	HL	Information Receiver Level	M	1			Required
LOOP ID - 2100B						>1
	050	NM1	Information Receiver Name	O	1			Required

LOOP ID - 2000C						>1
	010	HL	Service Provider Level	M	1			Required
LOOP ID - 2100C						>1
	050	NM1	Provider Name	O	1			Required

LOOP ID - 2000D						>1
	010	HL	Subscriber Level	M	1			Required
	040	DMG	Subscriber Demographic Information	O	1		N2/040	Situational
LOOP ID - 2100D						1
	050	NM1	Subscriber Name	O	1			Required

LOOP ID - 2200D						>1
	090	TRN	Claim Submitter Trace Number	O	1			Situational
	100	REF	Payer Claim Identification Number	O	1			Situational
	100	REF	Institutional Bill Type Identification	O	1			Situational
	100	REF	Medical Record Identification	O	1			Situational
	100	REF	Group Number	O	1			Situational
	110	AMT	Claim Submitted Charges	O	1			Situational
	120	DTP	Claim Service Date	O	1			Situational
LOOP ID - 2210D						>1
	130	SVC	Service Line Information	O	1			Situational
	140	REF	Service Line Item Identification	O	1			Situational
	150	DTP	Service Line Date	O	1			Required

LOOP ID - 2000E						>1
	010	HL	Dependent Level	O	1			Situational
	040	DMG	Dependent Demographic Information	O	1		N2/040	Required
LOOP ID - 2100E						1
	050	NM1	Dependent Name	O	1			Required

LOOP ID - 2200E						>1
	090	TRN	Claim Submitter Trace Number	O	1			Required
	100	REF	Payer Claim Identification Number	O	1			Situational
	100	REF	Institutional Bill Type Identification	O	1			Situational
	100	REF	Medical Record Identification	O	1			Situational
	110	AMT	Claim Submitted Charges	O	1			Situational
	120	DTP	Claim Service Date	O	1			Situational
LOOP ID - 2210E						>1
	130	SVC	Service Line Information	O	1			Situational
	140	REF	Service Line Item Identification	O	1			Situational
	150	DTP	Service Line Date	O	1			Situational
	160	SE	Transaction Set Trailer	M	1			Required

Pos	Id	Segment Name	Req	Max Use	Repeat	Notes	Usage
	GE	Functional Group Trailer	M	1			Required
	IEA	Interchange Control Trailer	M	1			Required

2/040	The DMG segment may only appear at the Subscriber (HL03=22) or Dependent (HL03=23) level.
2/040	The DMG segment may only appear at the Subscriber (HL03=22) or Dependent (HL03=23) level.