Claims Status API JSON-to-EDI Mapping

Preface

X12 is a non-profit organization chartered by the American National Standards Institute (ANSI) to develop and maintain business to business transaction standards. Several of the X12 Implementation Guides (X12 Type 3 Technical Report (TR3), also known as an X12 Implementation Guide (IG)) have been adopted under HIPAA for use by covered entities in the health care and insurance industry. These standards are widely adopted across providers, payers, and technology vendors such as Change Healthcare. These TR3s and the X12 metadata contained in them are intended to be used in conjunction with Change Healthcare’s APIs so that your organization will have access to the reference industry standards that include the codes and rules necessary to submit Eligibility, Claims, and Claim Status transactions. To obtain a license that also provides access to the full requirements for these transactions, you can visit https://x12.org/licensing. We make every effort to ensure consistency between Change Healthcare’s APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.

How to Use this Document

Use this document with our Open API Spec (Swagger) as a reference for development. Notes on the data in the following sections include:

A light blue table header row denotes each EDI segment.
The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: For example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
If a field is required, the Constraints entry notes it.

For the Constraints column in each table, the following letters stand for specific meanings:

R = Required (must be used if/when the object is part of the transaction);
S = Situational (may be required depending on how the transaction content is structured).

Situational loops, segments, or elements can be Situational in two forms:

Required IF a condition is met, but can be used at the discretion of the sender if it isn't required (for example, some descriptive notes can be added to a claim if necessary);
Required IF a condition is met, but if not, the sender must not use it in their request ("Do not send").

The Consolidated 276/277 Implementation Guide, p. 26 discusses this in further detail.

Claims Status 276 Request

Identification Leader (Request)

Providers (Request)

Subscriber (Request)

Dependent (Request)

Encounter (Request)

Claim Status 277 Response

Header (Response)

Payer (Response)

Providers (Response) 2100B/C

Subscriber (Response) 2100D

Dependent (Response) 2100E

Claims (Response) 2200D

Claim Status (Response) 2200D/E

Service Details (Response) 2220D/E

Error Response

Claim Status 277 Request

Identification Leader (Request)

Field	Description	C/R
`controlNumber`	Transaction Set Control Number. This is provided by the submitter. Unique ID used to trace the request. Value goes in ISA13 (no loop)	R 9/9
`tradingPartnerServiceId`	ID used by the CHC Clearinghouse for the trading partner. Loop 2100A, NM109. You can use the ConnectCenter CPID value as the `tradingPartnerServiceId`, from the searchable Change Healthcare Payer List.	2/80 R

Providers (Request) 2100B/C

Name	Element	Description	Constraints
`providers`(Object)		Generic for: 2100B - Billing (Information Receiver) 2100C - Service Providers	R
`organizationName`	NM103	Org name for provider. Can use organization or last name.	1/60 S
`firstName`	NM104	Maps to provider Name.	1/35 S
`lastName`	NM103	Maps to provider last name.	1/60 S
One of the following NM109 identifiers is Required for this object. Also see the requirements for each ID type.
`npi`	NM109	National Provider Identification Code Qualifier. Maps to provider `npi` when `providerType` = `ServiceProvider` NM108=XX – National Provider Identifier (NPI) for Medicare/Medicaid Loop 2100C only.	2/80
`tin`	NM109	National Provider Identification Code Qualifier. Maps to provider `tin` when `providerType` = `ServiceProvider` NM108=FI – Federal Taxpayer’s ID Loop 2100C only.	2/80
`spn`	NM109	National Provider Identification Code Qualifier. Maps to provider `spn` when `providerType` = `ServiceProvider` NM108=SV Service Provider Number, Loop 2100C only.	2/80
`taxId`	NM109	Billing Tax ID. Electronic Transmitter Identification Number (ETIN) used when `providerType` = `BillingProvider` Loop 2100B only.	2/80
`providerType`	NM109	Code for entity (Billing or Service) Billing Provider: Loop 2100B, NM101=41 (required) Service Provider: Loop 2100C, NM101=1P if not present it is added; tin = BillingProvider taxId ID	2/3

Subscriber (Request) 2100B/C

Name	Element	Loop	Description	Constraints
`subscriber`(Object)			The person that has the insurance policy.	R
`memberId`	NM109	2100D	The subscriber’s insurance member ID. Maps to `subscriberId`.	2/80 R
`firstName`	NM104	2100D	The subscriber’s first name as specified on their policy. Maps to subscriber `firstName`	1/35 S
`lastName`	NM103	2100D	The subscriber’s last name as specified on their policy. Maps to subscriber `lastName`.	1/60 S
`dateOfBirth`	DMG02	2000D	The subscriber’s birth date as specified on their policy Maps to subscriber `birthDate`.	1/35 R
`gender`	DMG03	2000D	The subscriber’s gender as specified on their policy. Required when available.	1/1 S
`groupNumber`	REF01	2200D	The subscriber’s group or policy number as specified on their policy. Maps to dependent `groupNumber`.	1/50 S