EDI 277 File: Health Care Claim Status Notification Transaction Set

The EDI 277 transaction set is essential for timely and accurate communication in healthcare billing. According to a report, EDI transactions account for 83% of all healthcare claims submissions. It allows healthcare providers and payers, including insurance companies and Medicare, to exchange claim status information electronically.

What is the EDI 277 Health Care Claim Status Notification Transaction Set? 

The EDI 277 Health Care Claim Status Notification Transaction Set, also known as EDI 277-A1, is an electronic data interchange (EDI) standard established by the ASC X12. The “A1” designation indicates that this specific transaction set adheres to the ASC X12 version 005010 standard. In simpler terms, it acts as a standardized electronic message format for conveying claim status information.

The EDI 277 transaction set can either be used as an insurance company’s electronic response to a previously received EDI 276-A1 or to request additional information from a healthcare provider without a submitted claim. It is generally used by healthcare payers such as insurance companies, Medicare, and others.

Workflow for the Exchange of EDI 277 File 

The exchange of EDI 277 files follows two main scenarios:

Solicited Status Inquiry (Provider Initiated)

Step 1: Claim Submission (Electronic or Paper)

• The healthcare provider prepares the submitted service’s claim details (patient, service, diagnosis).
• They can submit the claim electronically using a standardized format like CMS 1500 or UB-04 translated into an EDI transaction set (e.g., HIPAA 837).6

Step 2: Claim Processing by Payer

• The payer receives the claim information electronically or after manual data entry.
• The payer’s system processes the claim data using the received format (EDI).

Step 3: Claim Status Inquiry by Provider (EDI 276)

• The provider initiates an inquiry after a reasonable wait time and no updates.
• They create an EDI 276 claim status inquiry transaction set using EDI software.
• This EDI 276 document electronically transmits a request to the payer, which includes:

1. Patient information
2. Claim reference number
3. Date the claim was submitted

Step 4: Response from Payer (EDI 277)

• Upon receiving the EDI 276 inquiry, the payer retrieves the relevant claim information within the system.
• The payer uses an EDI 277 claim status response transaction to send the requested information to the provider electronically.
• This EDI 277 response includes:

1. Current claim status (received, pending, approved, denied)
2. Reason for denial (if applicable)
3. Estimated processing timeframe (if available)

Unsolicited Status Notification (Payer Initiated)

Step 1: Claim Submission

• Like solicited status inquiries, the provider submits the claim electronically or on paper.

Step 2: Claim Processing by Payer

• The payer receives and processes the claim information.

Step 3: Unsolicited Status Notification by Payer (EDI 277)

• The payer proactively sends the provider an EDI 277 claim status notification, even without a prior EDI 276 inquiry.
• This notification includes:

1. Current claim status (approved, denied, pending further information)
2. Reason for denial (if applicable)
3. Request for additional clarification needed to process the claim

EDI X12 277 File Format Sample

An EDI 277-A1 document is divided into functional groups that explain the transaction’s contents. A sample EDI 277-A1 document looks like this[1].

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *130924*0936*^*00501*000039422*0*P*~
GS*HN* SENDER *00000003B*20130924*0936*39421*X*005010X212~
ST*277*0001*005010X212~
BHT*0010*08*277005010X212E2*20130924*0536*DG~
HL*1**20*1~
NM1*PR*2*SAN FRANCISCO HEALTH PLAN*****PI*170558746~
PER*IC*EDI OPERATIONS*TE*8888808699*EX*4042*FX*6179235555~
HL*2*1*21*1~
NM1*41*1 A GOOD HOSPITAL *****46*1234567890~
HL*3*2*19*1~
NM1*1P*1*THE HOSPITAL*****XX*9876543210~
HL*4*3*22*0~
NM1*IL*1*DOE*JANE****MI*12345678901~
TRN*2*406ba0b7-700d-4c99-8c75-6da5adaf1da4~
STC*F1~65*20130924**1090*20.08*20130902**20130902*619524~
REF*1K*3239A7MW~
REF*EJ*61157208-000~
DTP*472*RD8*20130819-20130819~
SVC*HC~36415*25*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~80051*96*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~80076*101*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~82565*58*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~82947*66*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~84520*58*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~85025*92*20.08****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~85652*50*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SVC*HC~74020*544*0****1~
STC*P1~104*20130924~
DTP*472*RD8*20130819-20130819~
SE*44*0001~
GE*1*39421~
IEA*1*000039422~

EDI 277 Specification and File Components

The EDI 277 specification details the necessary elements for creating a valid claim status notification transaction. Both healthcare providers and payers need to understand these components to send and understand EDI 277 messages accurately.

Interchange Segments (ISA and GS)

These segments function like an electronic envelope, establishing the sender and receiver of the EDI transaction. They contain details like identification codes for both parties and the transaction date.

Transaction Set Header and Trailer Segments (ST and SE)

They define the specific transaction type (in this case, EDI 277) and mark the beginning and end of the actual claim status information within the EDI file.

Hierarchical Segments (HL)

Hierarchical segments establish a hierarchy within the data, indicating relationships between different message parts. For example, an HL can differentiate between the healthcare provider and the patient in the claim.

Entity Identifiers (NM1)

These segments identify the various entities involved in the claim process. This includes separate NM1 segments for the healthcare provider, the patient, and the payer organization.

Traceability Segments (TRN)

TRN provides unique tracking numbers for each claim status notification. This information helps ensure proper identification and follow-up within the healthcare billing system.

Demographic Information (DMG)

It captures essential demographic details about the patient associated with the claim, such as the patient’s date of birth.

Date/Time Segments (DTP)

These segments specify essential date and time details relevant to the claim, including the payer’s service or processing date.

Status and Code Segments (CAS, TE, and CLM)

These form the core of the EDI 277 message. They contain specific codes that indicate the claim’s status (approved, denied, pending), associated reasons for denial, and overall claim details.

Service Line Detail Segments (LX, SV1, and get amount Segments)

Sometimes, the EDI 277 transaction can convey detailed information about specific services or line items within a broader claim. These segments provide a breakdown of service codes, quantities, and potentially even payment details for each service line.

Monetary Amount Segments (CUR and MOA)

They specify the total claim amount, any amount paid by the payer, and potentially remaining patient responsibility. Monetary amount segments can also be used for specific service line breakdowns if applicable.

Reference Information Segments (REF)

REF can be used to include reference numbers for related transactions, such as the original claim submission (e.g., referencing a CMS 1500) or a prior claim status notification (e.g., referencing a previous EDI 277).

Achieve EDI Compliance with Astera EDIConnect

The EDI 277 transaction set facilitates effective communication about healthcare claim status. It allows healthcare providers and payers to share important claim status information electronically using a standard format, speeding up the billing process. With the right tool, handling the technical details of EDI 277 can become straightforward.

Astera EDI Connect offers a user-friendly interface that automates sending and receiving EDI 277 messages. You’ll get timely claim status updates directly from payers without dealing with complex details. Astera simplifies data processing and provides real-time monitoring of transactions, keeping you informed and in charge.

Contact us or download a free trial to ensure efficient claim status communication and optimize cash flow.

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