Medical Claim Life Cycle

ASC X12 270: Eligibility, Coverage, or Benefit Inquiry.

Difference between 277CA and 277

 

EDI 277 generated by the Payer whereas EDI 277CA generated by clearing house or payer or both.  EDI 277CA will be generated as soon as EDI 837 File is passed whereas  EDI 277 will be generated only upon request by EDI 276 transaction.

EDI 277CA will provide a claim level acknowledgement such as your claim is accepted or rejected.  But it does not guarantee that payment will be made.If accepted, an payer claim number will be generated and the same claim will pass to next level of process in the payer system called adjudication system. EDI 277 will be generated only if the claim is accepted and having an payer claim number.  If the claim is rejected at the 277CA level itself, then we cannot check the claim status because that claim is not in the payer adjudication system.

Today, many insurance companies respond to claims using their own report formats and/or electronic transaction formats. The ASC X12 277CA offers a common interface to the insurance company and the provider, thus standardizing the response. Because a claim may progress through several different statuses before reaching a final processing disposition, a provider may receive multiple ASC X12 277CA transactions for a single claim.

Sample EDI 277CA

ISA*00*          *00*          *ZZ*XXXXXXX        *ZZ*9085           *210301*1322*%*00501*000000000*0*P*:
GS*HN*XXXXXXX*9085*20210301*132234*1*X*005010X214
ST*277*0001*005010X214
BHT*0085*08*0001*20210301*132234*TH
HL*1**20*1
NM1*AY*2*XXXXX.XXXXXX*****46*XXXXX
TRN*1*000000001
DTP*050*D8*20210301
DTP*009*D8*20210301
HL*2*1*21*1
NM1*41*2*XXXXXX XXXXX LLC-TEST ACCOUNT*****46*9085
TRN*2*0001
STC*A1:19*20210301*WQ*120
HL*3*2*19*1
NM1*85*2*DEMO CLINIC*****XX*1215099528
TRN*1*0
HL*4*3*PT
NM1*QC*1*XXXXX*XXXXX****MI*XYZ312322
TRN*2*124309
STC*A7:21*20210301*U*120********Rendering NPI Fails LUHN check.
DTP*472*D8*20190604
SE*20*0001
GE*1*1
IEA*1*000000000