NRPM: Standards for Electronic Transactions. Standard: Health Claim Status (Subpart N)


[Please label any written comments or e-mailed comments about this section with the subject: Status]

a. Background

Health care providers need the ability to obtain up to date information on the status of claims submitted to health plans for payment, and the health plans need a mechanism to respond to these requests for information. The current processes are complicated by the diverse processes within health plan adjudication systems, which permit nonstandard information to be provided on the status of claims submitted. Most health care providers currently request claims status information manually. This requires health plans to provide information through various procedures that are costly and time consuming for all.

With the paper model of claims processing, inquirers who want to know the status of a claim they have submitted to a health plan call the health plan. An operator looks up the status via computer terminal or some other means and explains the status to the caller. The health claim status tells the inquirer whether the claim has been received, whether it has been paid, or whether it is stopped in the system because of edit failures, suspense for medical review or some other reason.

Many health plans have devised their own electronic claims status transactions since this is a function that is cheaper, easier, and faster to do electronically. This transaction eases administrative burden for both health plan and health care provider.

The ASC X12N Subcommittee established a workgroup (Workgroup 5 Claims Status) to develop a standard implementation with standard data content for all users of the ASC X12N 276/277 Health Care Claim Status Request and Response (004010X093).

The ASC X12N 276 is used to transmit request(s) for status of specific health care claim(s). Authorized entities involved with processing the claim need to track the claim’s current status through the adjudication process. The purpose of generating an ASC X12N 276 is to obtain the current status of the claim. Status information can be requested at various levels. The first level would be for the entire claim. A second level of inquiry would be at the service line level to obtain status of a specific service within the claim.

The ASC X12N 277 Health Care Claim Status Response is used by the health plan to transmit the current status within the adjudication process. This can include status in various locations within the adjudication process, such as pre- adjudication (accepted/rejected claim status), claim pending development, suspended claim(s) information, and finalized claims status.

Prior to the development of the ASC X12N 276/277 Health Care Claim Status Request and Response, there were very few proprietary or other electronic formats available for this type of claims status, and none were in widespread use. No existing standard was accepted for national use by the health care community. As researched by the HISB, only one standard could be considered for national implementation under HIPAA for health care claim status request and response: the ASC X12N 276/277 Health Care Claim Status Request and Response, version 3070.

i. Candidates for the Standard

The candidate standard for health care claim status is:

ASC X12N 276/277 Health Care Claim Status Request and Response, version 3070.

ii. Standard Selected

We propose to adopt ASC X12N 276/277 Health Care Claim Status Request and Response (004010X093), as the national standard for uniform use by health plans and health care providers for health care claims status.

HHS chose this standard primarily because of advice received from industry members. It met all 10 of the criteria used for assessing standards.

Data elements for the standard, and other information, may be found in Addendum 4.

b. Requirements

In § 142.1402, we would specify the following as the standard for health care claims status: ASC X12N 276/277 Health Care Claim Status Request and Response (004010X093). We would specify where to find the implementation guide and incorporate it by reference.

i. Health plans.

In § 142.1404, Requirements: Health plans, we would require health plans to use only the standards specified in § 142.1402 for electronic health care claims status transactions.

ii. Health care clearinghouses.

We would require in § 142.1406 that each health care clearinghouse use the standards specified in § 142.1402 for health care claims status.

iii. Health care providers.

In § 142.1408, Requirements: Health care providers, we would require each health care provider that transmits health care claim status requests electronically to use standards specified in § 142.1402 for those transactions.

c. Implementation Guide and Source

The implementation guide for the standard is available at no cost from the Washington Publishing Company site at the following Internet address: The data definitions and description of data conditions may also be obtained from this website.

Users without access to the Internet may purchase implementation guides from Washington Publishing Company directly: Washington Publishing Company, 806 W. Diamond Ave., Suite 400, Gaithersburg, MD, 20878; telephone 301-590-9337; FAX: 301-869- 9460.