EDI 276 File: Healthcare Claim Status Request Transaction Set

What is the EDI 276 Healthcare Claim Status Request Transaction Set?

The EDI 276-A1 Healthcare Claim Status Request transaction set is an electronic data exchange set used for claim status requests. Healthcare providers use it to verify the status of a claim previously submitted by a payer, such as an insurance company or a government scheme (Medicare). Recipients of healthcare services also use it to request status information on their outstanding claims.

This transaction set conveys information, including patient and provider identification details, date of service, subscriber information, and charges. The EDI 276-A1 and 277-A1 transaction sets are often used together in the healthcare data exchange and help healthcare service providers comply with Health Insurance Portability and Accountability Act (HIPAA) standards.

The “A1” number extension means that it follows the ASC X12 version 005010 of the EDI transaction set standard. This extension indicates the specific release and version of the transaction set, ensuring that all parties involved in the data exchange adhere to the same specifications for compatibility and accurate data interpretation.

Workflow for the Exchange of an EDI 276-A1 Health Care Claim Status Request

The EDI 276 document is transmitted to verify an EDI 837 Healthcare Claim. The EDI 837 document is used to submit healthcare claim information, including patient details, services provided, and costs. Once a claim has been submitted using EDI 837, the healthcare provider can use a healthcare claim status request (EDI 276) to receive updates on the status of the claim.

In response to an EDI 276-A1 transaction set, the healthcare payer first sends an EDI 999 Implementation Acknowledgment to confirm the arrival of a request. This transaction set assures the EDI 276 requests the sender of the receipt of their claim status inquiry.

Then, the healthcare payer sends an EDI 277-A1 Claim Status Response Transaction Set document with the claim details. The EDI 277-A1 provides details on whether the claim status is pending or finalized.

The healthcare payer may also send a 277 response document to request additional information about a claim, without receiving a 276 set. In such a case, the healthcare provider might send an EDI 275 Patient Information Transaction Set.

EDI X12 276 File Format Sample

An EDI 276-A1 document is divided into functional groups that explain the contents of the transaction being conducted. A typical EDI 276-A1 document looks like this[1]:

ISA *00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240718*1145*^*00501*000000001*0*T*>~

GS*HR*SENDERGS*RECEIVERGS*20240718*114512*000000001*X*005010~

ST*276*0046~

BHT*0010*13**20030109~

HL*1**20*1~

NM1*PR*2* PAYER NAME *****ZZ*ZZ~

PER*IC*PROVIDER CONTACT INFO*TE*6145551212~

HL*2*1*21*1~

NM1*41*2******46*111222333~

HL*3*2*19*1~

NM1*1P*2*PROVIDER NAME*****FI*FEDERAL TAX ID~

NM1*1P*2*PROVIDER NAME*****XX*NPI NUMBER~

NM1*1P*2*PROVIDER NAME*****SV*PROVIDER NUMBER~

HL*4*3*22*1~

NM1*IL*1*DOE*JOHN****MI*MEMBERID TRN*23*23~

HL*5*4*23~

DMG*D8*19171106*F~

NM1*QC*1*DOE*JANE~

TRN*1*500~

AMT*T3*68.69~

DTP*232*RD8*20021016-20021016~

SE*20*0046~

GE*1*000000001~

IEA*1*000000001~

EDI 276 Specification and File Components

An EDI 276-A1 file contains 16 key components, each with a specific purpose in the context of a healthcare claim status inquiry.

1. Interchange Control Header (ISA)
   • Identifies the start of an interchange of one or more functional groups.
2. Functional Group Header (GS)
   • Indicates the beginning of a functional group of related transaction sets.
3. Transaction Set Header (ST)
   • Indicates the beginning of the transaction set and assigns a control number.
4. Beginning of Hierarchical Transaction (BHT)
   • Identifies the beginning of a hierarchical transaction and provides the transaction reference number.
5. Hierarchical Level (HL)
   • Provides a hierarchical structure for the transaction set, allowing for the organization of data into parent-child relationships.
6. Information Source Level (NM1 – Payer)
   • Identifies the payer (insurance company) that is the source of the information.
7. Information Receiver Level (NM1 – Provider)
   • Identifies the provider (doctor, hospital, etc.) that is receiving the information.
8. Subscriber Level (NM1 – Subscriber)
   • Identifies the subscriber (patient) whose claim status is being inquired about.
9. Dependent Level (NM1 – Dependent, if applicable)
   • Identifies a dependent of the subscriber if the inquiry is about a dependent.
10. Claim Status Tracking Number (TRN)
    • Provides a tracking number for the claim status inquiry.
11. Service Line Information (SVC)
    • Provides details about the specific services rendered.
12. Claim Status Category Code (STC)
    • Provides the status of the claim.
13. Date (DTP)
    • Specifies dates related to the claim status inquiry.
14. Transaction Set Trailer (SE)
    • Indicates the end of the transaction set and provides the count of included segments.
15. Functional Group Trailer (GE)
    • Indicates the end of a functional group of related transaction sets.
16. Interchange Control Trailer (IEA)
    • Indicates the end of an interchange of one or more functional groups and interchange-related control segments.

Achieve EDI Compliance With Astera EDIConnect

Efficient management of healthcare data exchange is crucial for maintaining smooth operations and ensuring compliance with industry standards. The EDI 276 transaction plays a vital role in the healthcare industry by allowing providers to inquire about the status of a patient’s insurance claim electronically, accelerating the reimbursement process.

Managing EDI transactions like the EDI 276 requires robust tools that can offer data parsing, validation, mapping, and automation capabilities. Astera EDIConnect is an enterprise-grade EDI solution that simplifies the process of sending and receiving EDI 276/277 files. With a built-in EDI parser, validator, and transaction builder, Astera EDIConnect can handle transaction sets in ASC X12 and EDIFACT formats. It also offers code-free mapping of data to EDI formats and workflow automation to streamline the EDI process.

With Astera, you can streamline your healthcare data exchange while remaining HIPAA compliant, be it sending healthcare status claims or requesting claim updates.

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