Example 1: Claim Level Request and Response - Insured

Business Scenario Explanation:
ABC Insurance, which is the Information Source (Loop 2100A NM1), has a payer identification of 12345.

XYZ Service has an electronic transmitter identification number of X67E (Loop 2100B NM109), which it uses to conduct electronic business transactions with ABC Insurance.

Home Hospital uses XYZ Service to submit electronic health care claims and Health Care Claim Status Requests (276) to ABC Insurance (Loop 2100C NM1). Home Hospital's National Provider Identifier (NPI) is 1666666661.

Fred Smith is the Subscriber/Insured with an identification number of AAA123456789 (Loop 2100D NM109) and the group number is H32Q2 (Loop 2200D REF01 = 6P). Fred Smith's birth date is 12/10/1987 (Loop 2000D DMG). A Claim Status Trace Number of ABCXYZ1 (Loop 2200D TRN02) was assigned to the status request for Fred Smith's claim. Home Hospital requested the status of a claim for inpatient services, Bill Type 111 (Loop 2200D REF01 = BLT) for services August 31, 2025 through September 6, 2025 with a Total Claim Charge Amount of $8,513.88. Home Hospital included a Provider’s Assigned Claim Identifier of SM123456 (Loop 2200D REF01 = X1).

ABC Insurance located the specific claim and returned the corresponding Health Care Claim Status Response (277). The claim was received on September 10, 2025 (Loop 2200D DTP01 = 050) and it was assigned a Payer Claim Control Number of 05347006051 (Loop 2200D REF01 = 1K). As of the time of the Health Care Claim Status request, the claim had completed adjudication and was awaiting the payment/remittance cycle. ABC Insurance had not yet issued payment to Home Hospital and has not reported payment via a Health Care Claim Payment/Advice (835). As a result, the Health Care Claim Status Response reported Claim Status Category Code F1 – “Finalized/Payment-The claim/line has been paid” (Loop 2200D STC01-01) and Claim Status Code 3 – “Claim has been adjudicated and is awaiting payment cycle” (Loop 2200D STC01-02).