ASC X12 Version: 008030 | Transaction Set: 276/277 | TR3 ID: 008030X329
Example 6: Service Level Request and Response - Dependent
Business Scenario Explanation:
ABC Insurance, which is the Information Source (Loop 2100A), has a payer identification of 12345.
XYZ Service, the Information Receiver (Loop 2100B) has an electronic transmitter identification number of X67E, which it uses to conduct electronic business transactions with ABC Insurance.
Home Hospital Physicians, the Service Provider (Loop 2100C) uses XYZ Service to submit electronic claims and claim status requests to ABC Insurance. Home Hospital Physicians' National Provider Identifier (NPI) is 1234567891.
Joseph Smith, the patient, is a dependent (Loop 2100E) under Fred Smith's insurance. Fred Smith is the insured (i.e., subscriber, Loop 2100D), and his ABC Insurance member identification is WYX123456789. Joseph Smith's birth date is 11/01/2015 (Loop 2000E DMG). A Claim Status Trace Number of ABCXYZ3 (Loop 2200E TRN) was assigned to the status request for Joseph Smith's claim. Home Hospital Physicians requested the status of a service, procedure code 99214 and 5 HCPCS modifiers (Loop 2210E SVC) on May 1, 2025 with a Total Claim Charge amount of $150.00 (Loop 2200E AMT). Home Hospital Physicians provided a Provider's Assigned Claim Identifier of MA345678 (Loop 2200E REF01 = X1).
ABC Insurance (Loop 2100A) returned in the 277 Health Care Claim Status Response a Payer Claim Control Number of 051681010827 (Loop 2200E REF01 = 1K) to Joseph Smith's claim. The claim was denied as a duplicate. As a result, the 277 Health Care Claim Status Response reported Claim Status Category Code F2-"Finalized/Denial-The claim/line has been denied." (Loop 2220E STC01-01) and Claim Status Code 54-"Duplicate of a previously processed claim/line." (Loop 2220E STC01-02).
Corresponding Business Scenario Transaction
276 Request
HEADER
ST*276*0002*008030X329~
BHT*0010*13*00009467*20250515*1030~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – PAYER NAME
NM1*PR*2*ABC INSURANCE*****PI*12345~
LOOP ID 2000B – INFORMATION RECEIVER LEVEL
HL*2*1*21*1~
LOOP ID 2100B – INFORMATION RECEIVER NAME
NM1*41*2*XYZ SERVICE*****46*X67E~
LOOP ID 2000C – SERVICE PROVDER LEVEL
HL*3*2*19*1~
LOOP ID 2100C – SERVICE PROVIDER NAME
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1234567891~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*1~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*WYX123456789~
LOOP ID 2000E – DEPENDENT LEVEL
HL*5*4*23~
DMG*D8*20151101*M~
LOOP ID 2100E – DEPENDENT NAME
NM1*QC*1*SMITH*JOSEPH~
LOOP ID 2200E – CLAIM STATUS TRACE NUMBER
TRN*1*ABCXYZ3~
REF*X1*MA345678~
AMT*T3*150~
DTP*472*D8*20250501~
LOOP ID 2210E – SERVICE LINE INFORMATION
SVC*HC^99214^24^25^79^XE^^^XU*150*****1~
DTP*472*D8*20250501~
TRANSACTION SET TRAILER
SE*20*0002~
277 Response
HEADER
ST*277*0001*008030X329~
BHT*0010*08*00009467*20250515*1030*DG~
LOOP ID 2000A – INFORMATION SOURCE LEVEL
HL*1**20*1~
LOOP ID 2100A – PAYER NAME
NM1*PR*2*ABC INSURANCE*****PI*12345~
PER*IC**TE*3135551234~
LOOP ID 2000B – INFORMATION RECEIVER LEVEL
HL*2*1*21*1~
LOOP ID 2100B – INFORMATION RECEIVER NAME
NM1*41*2*XYZ SERVICE*****46*X67E~
LOOP ID 2000C – SERVICE PROVDER LEVEL
HL*3*2*19*1~
LOOP ID 2100C – PROVIDER NAME
NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1234567891~
LOOP ID 2000D – SUBSCRIBER LEVEL
HL*4*3*22*1~
LOOP ID 2100D – SUBSCRIBER NAME
NM1*IL*1*SMITH*FRED****MI*WYX123456789~
LOOP ID 2000E – DEPENDENT LEVEL
HL*5*4*23~
LOOP ID 2100E – DEPENDENT NAME
NM1*QC*1*SMITH*JOSEPH~
LOOP ID 2200E – CLAIM STATUS TRACE NUMBER
TRN*2*ABCXYZ3~
STC*F2^54*20250514**150*0*20250514~
REF*1K*051681010827~
REF*X1*MA345678~
DTP*472*D8*20250501~
DTP*050*D8*202510503~
LOOP ID 2220E – SERVICE LINE INFORMATION
SVC*HC^9921424^25^79^XE^^^XU*150*0****1~
STC*F2^54*20250514****20250514~
DTP*472*D8*20250501~
TRANSACTION SET TRAILER
SE*23*0001~