Example 5: Predetermination Estimation Claim

Business Scenario Description:
This scenario depicts a request and response for status of a medical predetermination/estimation claim that was previously sent in batch mode.

Business Scenario Explanation:
ABC Health Insurance, the Information Source, has a payer identification of 12345 (Loop 2100A NM109). XYZ Service, a Clearinghouse, has an Electronic Transmitter Identification Number of X67E (Loop 2100B NM109), which it uses to conduct electronic business transactions with ABC Health Insurance.

Home Hospital Physicians, NPI 1666666661 (Loop 2100C NM109), uses XYZ Service to submit electronic claims and claim status requests (including medical predetermination/estimation) to ABC Health Insurance. A medical predetermination/estimation claim had been previously submitted in batch mode to ABC Health Insurance. A response to the medical predetermination/estimation claim had not been received resulting in the submission of a medical predetermination/estimation Health Care Claim Status (276) transaction (BHT06=P5). XYZ Service submitted this to ABC Health Insurance on September 25, 2026.

Fred Smith is the patient applicable for this medical predetermination/estimation. His ABC Health Insurance Subscriber Identifier is 123456789 (Loop 2100D NM109) and his birth date is 12/10/1980 (Loop 2000D DMG02). The medical predetermination/estimation Health Care Claim Status (276) submitted is for knee replacement surgery, procedure code 27447 (Loop 2210D SVC01-02), for a Total Claim Charge amount of $10,000 (Loop 2200D AMT). Home Hospital Physicians had assigned a Claim Status Trace Number of BCWCC221 (Loop 2200D TRN02) to the medical predetermination/estimation Health Care Claim Status request. Home Hospital Physicians also included a Provider’s Assigned Claim Identifier of SM123456 (Loop 2200D REF01=X1). No date of service is submitted on a status request for a medical pre-determination/estimation claim.

ABC Health Insurance returned a medical predetermination/estimation (Loop 2200D STC13=08) Health Care Claim Status Response (277) transaction on September 25, 2026, which reported a Claim Status Category of F2 - Finalized/Denied (Loop 2200D STC01-01), a Claim Status Code of 21 – Missing or invalid information. Usage: At least one other status code is required to identify the missing or invalid information (Loop 2200D STC01-02), a second Claim Status Code of 255 – Diagnosis Code (Loop 2200D STC10-02), and a Status Information Effective Date of September 18, 2026 (Loop 2200D STC02). ABC Health Insurance had assigned Payer Claim Control Number EST2021265123 (Loop 2200D REF01=K1) to the original 837P medical pre-determination/estimation claim that had been received on September 15, 2026. To ensure internal tracking of the response to this medical predetermination/estimation Health Care Claim Status (277) transaction, ABC Health Insurance assigned an Information Source Application Trace Identifier of 96823749287 (Loop 2200A TRN02).