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.

Contents

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

FieldDescriptionC/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




NameElementDescriptionConstraints
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

  firstNameNM104Maps to provider Name.1/35 S
  lastNameNM103Maps 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






NameElementLoopDescriptionConstraints
subscriber(Object)The person that has the insurance policy.R
  memberId

NM109

2100D

The subscriber’s insurance member ID.
Maps to subscriberId.
2/80 S

  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 R


NameElementLoopDescriptionConstraints
dependent (Object)S
  firstName

NM104

2100E

Dependent’s first name.
Maps to dependent firstName.
1/35 R

  lastName

NM103

2100E

Dependent’s last name.
Maps to dependent lastName.
1/60 R

  gender


DM03


2000E


Dependent’s gender code.
Options: F or M.
Required if available.
1/1 S


  dateOfBirth

DM02

2000E

Dependent’s birth date.
Maps to dependent birthDate.
1/35 S

  groupNumber


REF01


2200E


The group number associated
with the dependent.
Maps to dependent groupNumber.
1/50 S


NameElementsDescriptionConstraints
encounter (Object)



The claim/encounter information,
for example a doctor visit.
Generic for: 2200D - Subscriber
2200E - Dependent
S



  beginningDateOfService

DTP03

Date Time Period: Start Date
maps to claimServiceDateStart.
1/35 R

  endDateOfService

DTP03

Date Time Period: End Date
maps to claimServiceDateEnd.
1/35 R

  trackingNumber

TRN02

The claim status tracking number assigned
to the status query for the claim.
1/50 R

  submittedAmount

AMT02

Submitted total charges. Value goes
in AMT02 where AMT01=T3 R
1/18 R

REF02 Values

Check the requirements for REF02
values and apply if known.
S

tradingPartnerClaimNumber



REF02



The payer assigned claim number.
Values go in REF02 where REF01=1K.
Required when a claim is
in the Information Source's system.
1/50 S



locationIdentifier


REF02


R if application or location system
identifier is known.
Value goes in REF02 where REF01=LU
1/50 S


billingType




REF02




Billing type reference ID.
Example: billing type for inpatient services is 111.
Value goes in REF02 where REF01=BLT.
Required for institutional claims
if search refinements are necessary.
1/50 S




patientAccountNumber

REF02

Patient account number provided by service provider.
Value goes in REF02 where REF01=EJ
1/50 S

pharmacyPrescriptionNumber



REF02



Patient pharmacy prescription number.
Value goes in REF02 where REF01=XZ
Required if a pharmacy claim
search needs additional search criteria.
1/50 S



clearingHouseClaimNumber


REF02


Required when there is a
Claim number provided by clearing house.
Value goes in REF02 where REF01=D9
1/50 S


NameDescription
controlNumberProvided by the submitter in the 270 Request. Transaction Set Control Number.
tradingPartnerServiceIdID used by Clearing House for the trading partner.

See the 276/277 Implementation Guide, pp. 224, and the OpenAPI spec for further details.

NameElementLoopDescriptionConstraints
payer
(Object)

The person
holding the
insurance policy.
S


  organizationName

NM103

2100A

Organization
Name, required.
2/80 R

  payerIdentificationNM1092100APayer identification2/80 R
  centersForMedicareAndMedicaidServicePlanId












NM109












2100A












Centers For
Medicare and
Medicaid Service
Plan Id. If
NM108 = XV,
this field
must be used
to push
the CMS ID
into NM109
as Payer ID
for this loop.
2/80 S












  contactInformation(Object)S
    name

PER02

2000A

Name of the
person to contact
1/35 S

    electronicDataInterChangeAccessNumber



PER[04,06,08]



2000A



Electronic Data
Interchange
Access
Number
1/256 S



    emailPER[04,06,08]2000Aemail1/256 S
    FaxPER[04,06,08]2000Afax1/256 S
    phonePER[04,06,08]2000Aphone1/256 S
    phoneExtensionPER[04,06,08]2000AvPhone Extension1/256 S

NameElementsDescriptionConstraint
providers
(Array of objects)

Generic for: Billing
(Information Receiver Loop 2100B)
Service Providers (Loop 2100C)
R


  organizationName

NM103

Provider’s organization name.
Can use organization or last name.
1/60 S

  firstName

NM104

Provider first name.
Maps to providerName
1/35 S

  lastName


NM103


Provider last name.
Can use organization or last name.
Maps to provider lastname.
1/60 S


One of the following
NM109 IDs is required.
  npi


NM109


National Provider Identification
Code Qualifier. Maps to provider npi.
NM108=XX
2/80 R


  taxId



NM109



Electronic Transmitter Identification
Number (ETIN). Established by Trading
Partner agreement.
NM108=FI
2/80 R



  providerType





NM101





Billing, Attending, Operating, Other Operating, Rendering
Code for entity (Billing or Service)
Billing Provider: Loop 2100B, NM101=41 (required)
Service Provider: Loop 2100C, NM101=1P
if this is not present it is added;
npi = BillingProvider taxId ID
2/3 R





NameElementDescriptionConstraints
subscriber (Object)R
  memberId

NM109

Member ID for the subscriber.
Maps to subscriberId.
2/80 R

  firstName

NM104

Subscriber’s first name.
Maps to subscriber firstName
1/35 S

  lastName

NM103

Subscriber’s last name.
Maps to subscriber lastName.
1/60 S

NameElementDescriptionConstraints
dependent (Object)S
  firstName

NM104

Dependent’s first name.
Maps to dependent firstName.
1/35 S

  lastName

NM103

Dependent’s last name.
Maps to dependent lastName.
1/60 S

See the 276/277 Implementation Guide, pp. 137, and the OpenAPI spec for further details.

NameElementDescriptionConstraints
claimStatus (Object)


Generic for:
2200D - Subscriber
2200E - Dependent
S


  statusCategoryCode

STC01-1

Healthcare claim status category code.
Code from a specific industry code list. Example: F3
1/30 R

  statusCategoryCodeValue


Value of the Status category code.
Example: F3=Finalized/Revised -
Changes to Adjudication information
1/30 R


  statusCode

STC01-02

Status of the claim or a service line.
Example: 3
1/30R

  statusCodeValue


Text describing the status code.
Example: 3=Claim has been adjudicated
and is awaiting payment cycle.
1/100 R


  entityCode

ST01-03

Code identifying an organizational entity,
location, property or an individual. Example: 2P
2/3 S

  entity

ST01-03

Text describing the entity code.
Example: 2P value is Public Health Service Facility
1/100 S

  effectiveDate


STC02


Date the claim was placed in this status by the
information source’s adjudication process.
Format: YYYYMMDD
8/8 R


  submittedAmount




STC04




Total claim charge amount. This value
may differ from the submitted total
claim charge due to claim splitting
and other claims processing
instructions.
1/18 S




  amountPaidSTC05Claim payment amount.1/18 S
  paidDate

STC06

Date of the denial or approval
of the claim. Format: YYYYMMDD
8/8 S

  checkIssueDate

STC08

Check issue or EFT funds
available date. Format: YYYYMMDD
8/8 S

  checkNumberSTC09Check or EFT trace number.1/16 S
  trackingNumber

TRN02

Referenced transaction trace number.
Provides unique ID for the transaction.
1/50 R

  claimServiceDate

DTP03

Claim service period.
Date or Date range, format YYYYMMDD
1/35 R

One REF02 value is required,
based on the REF01 code.
  tradingPartnerClaimNumber

REF02

The payer’s assigned control number.
REF01 = 1K
1/50

  patientAccountNumber

REF02

The Patient Account Number.
REF01 = EJ
1/50

  clearingHouseClaimNumber

REF02

The Clearing House Claim Number.
REF01 = D9
1/50

NameElementDescriptionConstraints
serviceDetails
(Array of Objects)

Generic for:
2200D - Subscriber
2200E - Dependent
S


  service (Object)

Required when status is
requested for Service Lines.
S

    serviceIdQualifierCode




SVC01-1




Code identifying the type/source of the
descriptive number in Product/Service ID.
Code Example: AD
See the X12 EDI 277
implementation guide for more details.
2/2 R




    serviceIdQualifier

String associated with the service code.
Example: American Dental Association Codes
1/100 R

    procedureIdSVC01-2Identifying number for a product or service.1/48 R
    submittedAmount


SVC02


Amount submitted for the service.
This is the line item total
on the current claim service status.
1/18 R


    amountPaidSVC03Amount paid for the service.1/18
    revenueCode

SVC04

National uniform billing
committee revenue code.
1/48 S

    submittedUnitsSVC07Original submitted units of service.1/15 R
  status (Array)
    statusCategoryCode

STC01-1

The health care claim status
category code. Example: F3
1/30 R

    statusCategoryCodeValue


Explanatory value of the category code.
F3 = Finalized/Revised -
Adjudication information has been changed
R


    statusCode

STC01-2

Status code used to identify the status of
an entire claim or a service line. Example: 3
1/30 R

    statusCodeValue


Status Code explanatory value.
3 = Claim has been adjudicated
and is awaiting payment cycle.
1/100 R


    entityCode


STC01-3


Code for the entity. Example: 2P
See the X12 EDI 277 implementation
guide for more details.
2/3 S


    entity

Explanatory value of the entity code.
Example: 2P = Public Health Service Facility
1/100 S

    effectiveDate




STC02




Effective date of the status information.
The date the service was placed in this status
by the information source’s
adjudication.
Date or Date range, format YYYYMMDD
8/8 R




NameDescription
errorResponse (Object)
  code

Code for the error.
Example: INVALIDMISSINGINPUTDATA
  description


Description of the error code.
Value provided in payer id
should be a valid CHC assigned ERA payer Id.
errors (Array of objects)
  fieldAttribute that is bad.
  valueValue of that attribute.
  codeCode for the error. Example: INVALIDVALUE
  location



Segment/location where error occurred.
If this is a network/system error,
there is no location attribute.
Example: $.payerBenefits[0].payer
  followupAction

Follow-up action required for the error.
For AAA errors, this is the value for AAA04

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