Questions Submitted by the Public, by Date Posted to the Website. Transaction standard for pre-adjudication claim edits


Should pre-adjudication claim edits be reported back to health care providers via an ANSI X12N 277 rather than the X12N 835 remittance transaction?

For example, a provider sends claims electronically using the X12N 837 claim standard to a health plan, the health plan compares the contents of the X12N 837 to a series of high-level mainframe edits before the claim enters into adjudication. At this point, claims are either accepted into the health plan's adjudication system or rejected back to the provider, so that the claims can be fixed and re-submitted.


The Secretary did not adopt a standard for reporting claim edit errors back to a health care provider. It is the health plan's decision as to whether it uses the unsolicited X12N 277 to send error messages back to the health care provider.