2017 © HAP Midwest Health Plan
HAP Midwest Health Plan, Inc
2850 W. Grand Blvd. Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
HAP Midwest Health Plan
HIPAA Transaction
Standard Companion Guide
American National Standards Institute
(ANSI) ASC X12N 277 (005010X214)
Health Care Claim Acknowledgement (277CA) OCTOBER 3, 2017
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783
hap.org/midwest 2
Disclosure Statement This companion document is the property of HAP Midwest Health Plan and is for use solely in your capacity as a trading partner of health care transactions with HAP Midwest Health Plan. It is incorporated by reference in the EDI Trading Partner Agreement.
Preface This document describes the components that are related to the file for the 277CA (Claims Acknowledgement) for Professional and Institutional EDI transactions.
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783
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EDITOR’S NOTE:
This page is blank because major sections of a book should begin on a right hand page.
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
Table of Contents
Disclosure Statement ........................................................................................................... 2
Preface .......................................................................................................................................................... 2 1 INTRODUCTION .......................................................................................................... 5
SCOPE ............................................................................................................ 5 REFERENCES ............................................................................................................. 5 ADDITIONAL INFORMATION ............................................................................. 6
2 GETTING STARTED .................................................................................................... 6 WORKING WITH HAP MIDWEST HEALTH PLAN .......................................... 6 TRADING PARTNER REGISTRATION .............................................................. 6 CERTIFICATION AND TESTING OVERVIEW ................................................... 6
3 TESTING WITH THE PAYER ....................................................................................... 6 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ............................................. 6
PROCESS FLOWS ............................................................................................. 6 COMMUNICATION PROTOCOL SPECIFICATIONS ......................................... 7 PASSWORDS ..................................................................................................... 7
5 CONTACT INFORMATION ............................................................................................... 7 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE ......................... 7 PROVIDER SERVICE NUMBER ..................................................................... 7 APPLICABLE WEBSITES/E-MAIL ................................................................... 8
6 CONTROL SEGMENTS/ENVELOPES ............................................................................ 8 ISA-IEA – ASC X12N 277 (005010X214) – 277 TRANSACTION INTERCHANGE
ENVELOPE AND FUNCTIONAL GROUP STRUCTURE ..................... 8 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ........................................... 8
STC COMPOSITE AND CODE USE RULES ..................................................... 8 MEMBER ID RULES ........................................................................................ 9 MAXIMUMS/LIMITATIONS.................................................................................. 9 REJECTED TRANSACTIONS/ACKNOWLEDGMENTS .................................... 9
8 ACKNOWLEDGEMENTS AND ERROR CODES .......................................................... 9 9 TRADING PARTNER AGREEMENTS ........................................................................... 13
DISCLAIMERS .............................................................................................. 13 10 TRANSACTION SPECIFIC INFORMATION ............................................................. 13
ASC X12N 277 (005010X214) – 277 TRANSACTIONS ................................. 13
Record of Changes ............................................................................................................ 19
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
1 INTRODUCTION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that HAP Midwest Health Plan has something additional, over and above, the information in the IGs. That information can:
• Limit the repeat of loops, or segments
• Limit the length of a simple data element
• Specify a sub-set of the IGs internal code listings
• Clarify the use of loops, segments, composite and simple data elements
• Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with HAP Midwest Health Plan
In addition to the row for each segment, one or more additional rows are used to describe HAP Midwest Health Plan’s usage for composite and simple data elements and for any other information. Notes and comments specify detailed information. In the example below, a note about a code value about the segment is shown.
TR3 Page #
Loop ID Segment Data Element
Data Element Name
Business Rules/Notes
47 2100B NM1 - INFORMATION RECEIVER NAME
NM101 Name Last or Organization Name
Information Receiver’s name will be returned
SCOPE
The Health Insurance Portability and Accountability Act-Administration Simplification (HIPAA-AS) requires HAP Midwest Health Plan to comply with the electronic data interchange standards for health care as established by the Department of Health and Human Services and Medicare requirements for CMS.
This document is intended for use as a companion to the HIPAA-mandated ASC X12N/005010X214 277 TR3, dated January 2007. Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the noted HIPAA TR3 published by Washington Publishing Company.
This guide should not be confused with the 276/277 Claims Status Request and Response implementation.
The 277CA transaction set is generated for a submitter who is already successfully submitting 837 claim (professional/institutional) transactions. This document contains HAP Midwest Health Plan’s specifications for the transaction set as well as contact information and key points.
REFERENCES
To obtain any or all of the HIPAA mandated 005010 ASC X12 TR3s, please visit X12’s website http://store.x12.org/store/, or Washington Publishing Company’s website http://www.wpc-edi.com
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
To obtain Health Care Code Lists, please refer to Washington Publishing Company’s website:
http://www.wpc-edi.com/reference/ . The Washing ton Publishing Company’s website provides the Claim Status codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ and
Claim category codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status- category-codes/ for 277 Claims acknowledgement implementation.
Visit http://www.michigan.gov/mdch/ for Michigan Department of Community Health information and instructions.
For Medicare-Medicaid updates refer to http://www.cms.gov/
For Core Rules HIPAA 5010 updates refer to information on http://www.caqh.org/COREv5010.php
ADDITIONAL INFORMATION
Additional information will be provided to trading partners upon request.
2 GETTING STARTED WORKING WITH HAP MIDWEST HEALTH PLAN
277CA is the unsolicited electronic claim acknowledgement in ASC X12N 5010 x214 format. The transaction identifies claims that are accepted as well as claims that were rejected along with claim status codes that indicate the errors. Claims acknowledgement transaction set will be generated along with the 5010 999 Acknowledgement transaction set for trading partners that submit V5010 EDI transactions. In addition, HAP Midwest Health Plan will continue to return the EDI Claim Errors report.
To receive more information or ask questions, please contact Customer Service at 888-654-2200. HAP Midwest Health Plan website www.midwesthealthplan.com/ContactUs.aspx lists additional contact information.
A 277CA acknowledgement is not a guarantee of payment. The status information provided is based on the claim’s characteristics at the time the claim transactions are processed.
TRADING PARTNER REGISTRATION
Providers must complete a HAP Midwest Health Plan Trading Partner Agreement (TPA) prior to submitting V5010 EDI transactions.
CERTIFICATION AND TESTING OVERVIEW
HAP Midwest Health Plan does not require or provide certification for its trading partners.
3 TESTING WITH THE PAYER 277 Claims Acknowledgement implementation will be tested with new trading partners as part of the 5010 EDI transactions submissions testing. Trading Partners should submit test files containing a minimum of 25 test claims that accurately represent the type of claims that will be submitted in production.
4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
To receive the 277 Claim Acknowledgement transactions you must be a registered user with a password and already be submitting HIPAA-compliant 837 files (professional and/or institutional) directly to HAP Midwest health Plan.
COMMUNICATION PROTOCOL SPECIFICATIONS
Please refer to the HAP Midwest Health Plan Providers Administrative Manual for information regarding:
- Submitter setup and trading partner B2B testing
- Direct upload to HAP Midwest Health Plan using HTTPS secure file upload
- Secure FTP submission
- Interchange Acknowledgement (999) transaction
PASSWORDS
HAP Midwest Health Plan requires a password to submit requests. The password could be set up after trading partner agreements have been signed.
5 CONTACT INFORMATION EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE
Technical assistance will be provided upon request. For questions regarding 277CA transactions, please send email to [email protected] and type in “edi277CA” as the prefix in the Subject field for expedited assistance.
PROVIDER SUPPORT NUMBER
HAP Midwest Health Plan: (313)-664-8763
APPLICABLE WEBSITES/E-MAIL
HAP Midwest Health Plan website www.midwesthealthplan.com
Additional contact information is listed at http://www.midwesthealthplan.com/ContactUs.aspx
837 Institutional
Claims
HAP MIDWEST HEALTH PLAN
837 Professional
Claims
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
6 CONTROL SEGMENTS/ENVELOPES ISA-IEA – ASC X12N 277 (005010X214) – 277 TRANSACTION INTERCHANGE ENVELOPE AND FUNCTIONAL GROUP STRUCTURE
This section describes HAP Midwest Health Plan’s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information and delimiters.
TR3 Page
#
277 Loop ID
277 Segment
277Data Element
277 Data Element Name
Business Rules/Notes
C.4 ISA ISA – Interchange Control Header
ISA05 Interchange ID Qualifier
“ZZ” will be shown
C.5 ISA ISA – Interchange Control Header
ISA06 Interchange Sender ID
ID that corresponds to the Receivers ID on the 837 will be present
C.5 ISA ISA – Interchange Control Header
ISA07 Interchange ID Qualifier
“ZZ” will be shown
C.5 ISA ISA – Interchange Control Header
ISA08 Interchange Receiver ID
Sender ID that is on the corresponding 837 will be shown
C.6 ISA ISA – Interchange Control Header
ISA15 Usage Indicator “P” for production/”T” for test
C.7 GS GS – Functional Group Header
GS02 Application Sender’s Code
HAP Midwest Health Plan ID will be present
C.7 GS GS – Functional Group Header
GS03 Application Receiver’s Code
ID mutually agreed for transmissions will be shown
C.9 GE GE – Functional Group Trailer
GE01 Number of Transaction Sets Included
Total number of transaction sets included in the functional group will be listed
C.9 GE GE – Functional Group Trailer
GE02 Group Ctrl Number The number sender assigned is shown
HAP Midwest Health Plan’s utilizes the following characters as delimiters on outgoing 277CA transactions.
Delimiters/Separators Character Description
Asterisk * Data element separator
Carat ^ Repeating data element separator
Colon : Composite data element separator
Tilde ~ Terminator
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS STC COMPOSITE AND CODE USE RULES
HAP Midwest Health Plan supports the following use of composites and codes within the STC segment. The STC segment contains the composite of three STCs, STC01, STC10 and STC11.
• STC01 is required and displays the Acknowledgement Code Status code and entity codes as they apply.
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• STC10 and STC11 are situational and provide additional clarification to STC01 displaying additional status and entity codes. For example, when Billing Provider’s NPI is not valid, the status codes will be shown utilizing STC10-1, STC10-2 and STC10-3 fields. STC*A7:21*20140825*U*1469.25******A7:562:85~
• Multiple STC segments will be reported for unrelated status codes
MEMBER ID RULES
Member ID is 10 digits Beneficiary ID for MEDICAID, Healthy Michigan Plan and ABW members (0012345678), 9 digits ID for HAP Midwest Advantage Medicare members (000991234), 9 digits ID for Wayne County Health Choice Members (120012345), and alpha-numeric ID for Macomb Care Connect (B0502001).
MAXIMUMS/LIMITATIONS This implementation is intended to support use in batch mode.
REJECTED TRANSACTIONS/ACKNOWLEDGMENTS
Transactions that contain an unauthorized submitter identification number, invalid submitter/provider combinations or are HIPAA non-compliant are rejected and 999 transaction(s) will be returned as defined in the 837 EDI process. The 999 transaction(s) will specify the rejection with error code(s).
8 ACKNOWLEDGEMENTS AND ERROR CODES Rejection Criteria/Error Messages on the 277CA Acknowledgement
Code Claim Status Category Description
A0 Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity. A1 Acknowledgement/Receipt – The claim/encounter has been received.
A2 Acknowledgement/Receipt – The claim/encounter has been received.
A3 Acknowledgement/Returned as unprocessable claim – The claim/encounter has been rejected. The claim must be resubmitted.
A4 Acknowledgement/Not Found – The claim/encounter cannot be found
A6 Acknowledgement/Rejected for Missing Information – The claim/encounter is missing the information specified in the Status details and has been rejected
A7 Acknowledgement/Rejected for Invalid Information – The claim/encounter has invalid information as specified in the Status details and has been rejected.
A8 Acknowledgement/Rejected for relational field in error.
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
Rejection Criteria/Error Messages on the 277CA Acknowledgement
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Claim Status Code Description
A Code STC01-1
277 Status Code STC01-2
Entity/ Status Code STC01-3
Additional Status Code STC10-2
Additional Entity/Status Code STC-10-2
Invalid PCDCD A7 21 454
Invalid PCDCD Modifier A7 21 453
Invalid PCDCD Date A7 21 454
Missing PCDCD Qualifier A6 21 454
Missing Rev Code A6 21 455
Missing HCPC Code A6 21 454
Invalid Service Line A7 21 247
Invalid Vendor Address A7 21 126 87
Missing Procedure Code A6 21 454
Invalid Diagnosis Code A7 21 255
Invalid Diagnosis Code Date A7 21 557
Missing Provider NPI A6 562 85
Missing Provider Tax ID A6 128 85
Missing Provider DOS A6 187
Billing Provider Not Found A7 26 85
Rendering Provider Not Found A7 26 82
Place Of Service Or Encounter Reason Not Found
A7 21
A7 249
Multiple Members Found A8
Member Not Found A7 32
Too Many Services (999) A7 121
Too Many PCDCDE (36) A7 121
Missing or Invalid Diagnosis Code Pointer
A7 477
Plan Type Frequency Code Mismatch
A8
PCDCD Quantity less than 1 A7 476
Service Date in Future A7 510 187
Missing or Invalid Ambulance Transport Info - CR1
A6 21
266
External cause of injury invalid as primary diagnosis
A7 21
255
Invalid Quantity A7 476
Billing Provider NPI Not Valid A7 21 562 85
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Claim Status Code Description
A Code STC01-1
277 Status Code STC01-2
Entity/ Status Code STC01-3
Additional Status Code STC10-2
Additional Entity/Status Code STC-10-2
Rendering Provider NPI Not Valid A7 21 562 82
Referring Provider NPI Not Valid A7 21 562 DN
Invalid Admission/Discharge Hour A7 21 230 233
Invalid NDC Unit Code A7 21 218
Duplicate PCDCD Modifier A7 453
Missing PCDCD Modifier A6 21 453
Attending Provider NPI Not Valid A7 21 562 71
Missing Attending Provider NPI A6 21 562 71
Missing Attending Provider A6 132 71
Admission Date In Future A7 510 189
Invalid Admission Date A7 21 189
Missing Rendering Provider Name A6 21 125 82
Operating Provider NPI Not Valid A7 21 562 72
Other Operating Provider NPI Not Valid
A7 21
562 72
Missing Attending Provider Name A6 21 125 71
Facility Zip must be 9 digits A7 21 500 FA
Billing Provider Zip must be 9 digits
A7 21
500 85
Facility Address Required A6 21 126 77
Service Facility NPI Not Valid A7 21 562 77
Mixed ICD Diagnosis Versions A7 21 557
ICD-9 Code billed after ICD-10 GoLive Date
A7 21
557
ICD-10 Code billed before ICD-10 GoLiveDate
A7 21
557
Missing Diagnosis Qualifier A6 21 754 255
Only 1 rendering allowed per claim
A7 732
170 82
Admission Type not Valid for Inpatient Claim
A7 250
V-code not valid as primary diagnosis
A7 21
254
Inpatient claim must have admit date
A6 21
189
Principle diagnosis missing A6 21 255
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VERSION 5010
Claim Status Code Description
A Code STC01-1
277 Status Code STC01-2
Entity/ Status Code STC01-3
Additional Status Code STC10-2
Additional Entity/Status Code STC-10-2
Surgical Code Not Valid A7 21 666
Admit Date Cannot be in the Future
A7 510
188
Procedure Quantity Cannot be Blank
A7 476
Claim still in process over 99 lines A1 277 PR
Discharge Date cannot be in the future
A7 510
190
Invalid Discharge Date A7 21 190
Inpatient claim must have admit date
A7 21
189
Detail Line Total does not equal total submitted charges
A7 21
178
Adjudication errors A7 710
Diagnosis not enough digits A7 21 255
G/L Distribution Code not found – System Error
A8 33
Price Category/Modifier not Found
A7 21
453
Multiple Providers Found A8
Contract History Record is Expired A7 29
Claim Contains Over 26 Duplicate Procedures on the Same Day
A7 54
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VERSION 5010
9 TRADING PARTNER AGREEMENTS An EDI Trading Partner is defined as any provider, billing service or clearing house that transmits to and receives electronic data from HAP Midwest Health Plan.
HAP Midwest Health Plan has EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.
DISCLAIMERS
This document has been prepared as a HAP Midwest Health Plan specific companion document to ASC X12N 277 (005010X214) implementation guide and to provide instructions to trading partners for the data elements. This companion guide document supplements, but does not contradict any requirements in the implementation guide.
10 TRANSACTION SPECIFIC INFORMATION ASC X12N 277 (005010X214) – 277 TRANSACTIONS
The following section addresses specific information HAP Midwest Health Plan will return within the ASC X12N 277 (005010X214) 277 Transaction. This information should be used in conjunction with the ASC X12N 277 (005010X214) 277 TR3.
TR3 Page
#
277 Loop
277 Segment
277Data Element
277 Data Element Name
Business Rules/Notes
38 2100A NM1 - INFORMATION SOURCE NAME
NM101 Entity Identifier Code
‘PR” will be returned
38 2100A NM1 - INFORMATION SOURCE NAME
NM103 Name Last or Organization Name
“HAP MIDWEST HEALTH PLAN.
INC” will be returned
38 2100A NM1 - INFORMATION SOURCE NAME
NM108 ID Code Qualifier
“PI” will be returned
39 2100A NM1 - INFORMATION SOURCE NAME
NM109 Identification Code
“MHP77” will be returned
40 2200A TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER
TRN02 Reference Identification
Unique trace number that identifies transaction will be returned
47 2100B NM1 - INFORMATION RECEIVER NAME
NM101 Entity Identifier Code
“41” will be returned
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47 2100B NM1 - INFORMATION RECEIVER NAME
NM103 Name Last or Organization Name
Information receiver’s name will be returned
48 2100B NM1 – INFORMATION RECEIVER NAME
NM108 ID Code Qualifier
“46” will be returned
48 2100B NM1 - INFORMATION SOURCE NAME
NM109 Identification Code
Information receiver’s primary identifier will be returned
49 2200B TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER
TRN02 Reference Identification
Value submitted in the BHT03 data element from 837 is returned
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-1 Health Care Claim Status Category Code
A1 = Acknowledgement/Receipt- The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-2 Health Care Claim Status Category Code
19 = Entity acknowledges receipt of claim/encounter
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-3 Health Care Claim Status Category Code
“41” will be returned to indicate submitter
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC02 Date Status information effective date will be shown
52 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC03 Action Code “WQ” for Accept which is the default value representing transaction level acceptance. Specific rejections/acceptance will be reported in Loop 2200D. If the entire transaction set is rejected “U” will be returned.
52 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC04 Monetary Amount
Monetary sum of all claims within ST-SE transaction set
55 2200B QTY – TOTAL ACCEPTED QUANTITY
QTY01 Quantity Qualifier
“90” will be returned
55 2200B QTY – TOTAL ACCEPTED QUANTITY
QTY02 Quantity Total accepted quantity
56 2200B QTY – TOTAL REJECTED QUANTITY
QTY01 Quantity Qualifier
“AA” will be returned
56 2200B QTY – TOTAL REJECTED QUANTITY
QTY02 Quantity Total rejected quantity for information receiver (not created if all claims are accepted)
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57 2200B AMT - TOTAL ACCEPTED AMOUNT
AMT01 Amount Qualifier Code
“YU” = In Process (not created when all claims are
rejected)
57 2200B AMT - TOTAL ACCEPTED AMOUNT
AMT02 Monetary Amount
Total accepted amount
58 2200B AMT - TOTAL REJECTED AMOUNT
AMT01 Amount Qualifier Code
“YY” = Returned (not created when all claims are
accepted) 58 2200B AMT - TOTAL
REJECTED AMOUNT
AMT02 Monetary Amount
Total rejected amount
61 2100C NM1 – BILLING PROVIDER NAME
NM101 Entity Identifier Code
“85” Billing Provider
62 2100C NM1- BILLING PROVIDER NAME
NM108 Identification Code Qualifier
“XX”
62 2100 NM1 – BILLING PROVIDER NAME
NM103 & NM104
Name Last or Organization Name & Name First
Providers name NM104 is used when Provider is Type 1
62 2100C NM1 - BILLING PROVIDER NAME
NM109 Identification Code
National Provider ID will be returned
64 2200C TRN - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER
TRN01 Trace Type Code
“1” will be returned to indicate current transaction numbers
64 2200C TRN - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER
TRN02 Reference Identification
Reference information as defined for a particular transaction set
65 2200C STC - BILLING PROVIDER STATUS INFORMATION
STC01-1 HEALTH CARE CLAIM STATUS
See Rejection Criteria/Error Messages on the 277CA Acknowledgement
65 2200C STC - BILLING PROVIDER STATUS INFORMATION
STC01-2 HEALTH CARE CLAIM STATUS
See 277 codes on http://www.wpc- edi.com/reference/
65 2200C STC - BILLING PROVIDER STATUS INFORMATION
STC01-3 HEALTH CARE CLAIM STATUS
“41” will be returned for submitter
66 2200C STC - BILLING PROVIDER STATUS INFORMATION
STC03 HEALTH CARE CLAIM STATUS
“U”/”WQ will be returned to indicate rejected/accepted
67 2200C STC - BILLING PROVIDER STATUS INFORMATION
STC04 HEALTH CARE CLAIM STATUS
Monetary amount will be indicated
71 2200C STC - BILLING PROVIDER STATUS INFORMATION
QTY01 Quantity Qualifier
“QA” – Total Accepted Quantity/”QC” – Total Rejected Quantity will be returned
72 220C STC - BILLING PROVIDER
QTY02 Quantity Quantity that was rejected/quantity that was
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STATUS INFORMATION
accepted will be returned
74 2200C STC - BILLING PROVIDER STATUS INFORMATION
AMT01 Quantity Qualifier
“YU” – In process / “YY” – Rejected will be returned as appropriate
77 2100D PATIENT NAME NM101 Entity Identifier Code
"QC" will be returned
77 2100D PATIENT NAME NM102 Entity Type Qualifier
"1" will be returned
77 2100D PATIENT NAME NM103 Name Last or Organization Name
Subscriber's Last Name
77 2100D PATIENT NAME NM104 Name First Subscriber's First Name 2010BA NM105
78 2100D PATIENT NAME NM108 Identification Code Qualifier
“MI” will be returned
78 2100D PATIENT NAME NM109 Identification Code
Patient Identification Number is returned
79 2200D TRN – CLAIM STATUS TRACKING NUMBER
TRN01 Trace Type Code
“2” – Referenced transaction trace numbers
79 2200D TRN – CLAIM STATUS TRACKING NUMBER
TRN02 Reference Identification
Patient control number will be returned
80 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC01-1 Industry Code See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
81 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC01-2 Industry Code See 277 Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
81 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC01-3 Entity Identifier Code
‘41’ will be returned to indicate entity associated with the claim.
See Entity/Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
82 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC10-1 Health Care Claim Status Code
See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
83 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC10-2 Health Care Claim Status Code
See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
83 2200D STC- CLAIM LEVEL STATUS INFORMATION
STC10-3 Entity Identifier Code
See Additional Entity/Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3781
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COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
85 2200D REF- PAYER CLAIM CONTROL NUMBER
REF01 Reference Identification Qualifier
“1K” for Payer’s claim number will be returned.
85 2200D REF- PAYER CLAIM CONTROL NUMBER
REF02 Reference Identification
Payer claim control number will be returned.
86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES
REF01 Reference Identification Qualifier
“D9” will be returned when a clearing house tracking number is received in 837
86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES
REF02 Reference Identification
Clearing house tracking number is returned if received in 837
87 2200D REF- INSTITUTIONAL BILL TYPE IDENTIFICATION
REF01 Reference Identification Qualifier
“BLT” will be returned to indicate Institutional Bill Type identifier (Applies to Institutional claims)
87 2200D REF - INSTITUTIONAL BILL TYPE IDENTIFICATION
REF02 Reference Identification
Institutional Type of Bill received on the claim will be returned (Applies to Institutional claims)
87 2200D DTP - CLAIM LEVEL SERVICE DATE
DTP01 Date/Time Qualifier
“472” indicating Service will be returned
89 2200D DTP - CLAIM LEVEL SERVICE DATE
DTP02 Date Time Period Format Qualifier
D8/RD8 depending if the service period is a date or range of dates
89 2200D DTP - CLAIM LEVEL SERVICE DATE
DTO03 Date Time Period
Service date
90 2220D SVC - SERVICE LINE INFORMATION
SVC01 Composite Medical Procedure
This field will be populated with the values received from 837 Professional or 837 Institutional Service Line Information when service line has an error. The following fields will indicate associated errors.
94 2220D STC- SERVICE LINE LEVEL STATUS INFORMATION
STC01-1 Health Care Claim Status Code
See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
95 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC01-2 Health Care Claim Status Code
See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
96 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC01-3 Health Care Claim Status Code
Entity Code ‘41’ – Submitter will
be returned. See Additional Entity/Status Code in section Rejection Criteria/Error
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3781
hap.org/midwest 18
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
Messages on the 277CA Acknowledgement
96 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC10-1 Health Care Claim Status Code
See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
96 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC10-2 Health Care Claim Status Code
See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
97 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC10-3 Health Care Claim Status Code
See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
99 2220D REF- SERVICE LINE ITEM IDENTIFICATION
REF02 Reference Identification
Present only when service line has error(s). Line item control number will be returned
101 2220D DTP - SERVICE LINE DATE
DTP01 Date Time Period
Present only when service line has error(s). Service line date or date range will be returned
2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3781
hap.org/midwest 19
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
Record of Changes
Version
Number
Date
Author/Owner
Description of Change
1 07/8/2014 HAP Midwest Health Plan
Document created for testing with trading partners
2 10/10/2014 HAP Midwest Health Plan
Document revised to include additional error codes