11 Appendix A 5 2 277 Version 5010 BRC 11 24 2009 by rLUa144Z

VIEWS: 5 PAGES: 17

									                                                                                                                                                                                                                                                                                                           New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                         Business Rules Comparion
                                                                                                                                                                                                                                                                                                             277 Health Care Claim Status Response




                                                                                            ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                            MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                       N
                                                                                                                                                                                                                                                                                                                All the active claims database (including
                                                                                                                                                                                                                                                                                                                suspended claims) and on the claims history
                                                                                                                                                                                                                                                                                                                database are available for online inquiry by TCN,
                                                                                                                                                                                                                                                                                                                billing provider number, or client id number. The
                                                                                                                                                                                                                                                                                                                primary search criteria may be further limited by a
                                                                                                                                                                                                                                                                                                                variety of additional selection criteria: header level
                                                                                                                                                                                                                                                                                                                rendering provider number, line item rendering
                                                                                                                                                                                                                                                                                                                provider number, claim type, prior authorization
                                                                                                                                                                                                                                                                                                                number, dates of service (from/through range),
                                                                                                                                                                                                                                                                                                                dates of payment (from/through range), total
                                                                                                                                                                                                                                                                                                                allowed charge, patient account number, and
                                                                                                                                                                                                                                                                                                                attending physician number.

        Header    Table 1 - Header

                                                                                                                                   To indicate the start of a transaction set and to assign a control
                                                               Transaction Set
1.0     Header                                      0100 ST                      R   1                                             number. The information in the Header of the Transaction is
                                                               Header
                                                                                                                                   based on the Payer and Receiver's information.

                                                                                                                                 The transaction set identifier used by the translation routines of
                                                                                                                                 the interchange partners to select the appropriate transaction
                                                                                                 Transaction Set
2.0     Header                                                                           ST01                       R   ID   3/3 set definition.
                                                                                                 Identifier Code
                                                                                                                                 May contain '277' ONLY for this transaction set.
                                                                                                                                 Set to '277' - Health Care Claim Status Notification.
                                                                                                                                   Identifying control number that must be unique within the
                                                                                                 Transaction Set                   transaction set functional group assigned by the originator for a                                                                                                            Following the 835 convention, use Julian date
3.0     Header                                                                           ST02                       R AN     4/9
                                                                                                 Control Number                    transaction set.                                                                                                                                                             appended with seq'l number.
                                                                                                                                   The value in ST02 must be identical to SE02.
                                                                                                 Implementation
4.0     Header                                                                           ST03    Convention         R AN 1/35 Set to 005010X212
                                                                                                 Reference
                                                               Beginning of                                                        To define the business hierarchical structure of the transaction
5.0     Header                                      0200 BHT   Hierarchical      R   1                                             set and identify the business application purpose and reference
                                                               Transaction                                                         data, I.e., number, date and time.
                                                                                                                                 Code indicating the hierarchical application structure of a
                                                                                                                                 transaction set that utilizes the HL segment to define the
                                                                                                 Hierarchical
6.0     Header                                                                           BHT01                      R   ID   4/4 structure of the trans set.
                                                                                                 Structure Code
                                                                                                                                 Set to is '0010' - Information Source, Information Receiver,
                                                                                                                                 Provider of Service, Subscriber, Dependent.
                                                                                                 Transaction Set                   Code identifying purpose of transaction set.
7.0     Header                                                                           BHT02                      R   ID   2/2
                                                                                                 Purpose Code                      Set to '08' - Status
                                                                                                 Originator
                                                                                                                              This is the number assigned by the originator to identify the
                                                                                                 Application
8.0                                                                                      BHT03                      R AN 1/50 transaction within the originator's business application system.
                                                                                                 Transaction
                                                                                                                              Set to '277X212'
                                                                                                 Identifier
                                                                                                 Transaction Set                   Format is CCYYMMDD. This is the date the transaction was
9.0     Header                                                                           BHT04                      R DT     8/8
                                                                                                 Creation Date                     created within the business application system.
                                                                                                 Transaction Set
10.0    Header                                                                           BHT05                      R TM     4/8 Time expressed in 24-hr clock time.
                                                                                                 Creation Time
                                                                                                 Transaction Type
11.0    Header                                                                           BHT06                      R   ID   2/2 Set to 'DG' - Response
                                                                                                 Code
                  Table 2 - Detail,
12.0              Information Source
                  Level
                  Information Source
13.0    2000A                                 >1
                  Level




                                                                                                                                                                    Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                   Page: 1 of 17                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                              New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                            Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                277 Health Care Claim Status Response




                                                                                          ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                                 MMIS SPECIFICATIONS




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                                                               Hierarchical                                                         To identify dependencies among and the content of
14.0    2000A                                       0100 HL                    R   1
                                                               Level                                                                hierarchically related groups of data segments.

                                                                                                                                                                                               HL01 will contain a unique
                                                                                                                                                                                               alphanumeric number for each
                                                                                                                                                                                               occurrence of the HL segment
                                                                                                                               A unique number assigned by the sender to identify a particular in the trans set. For example,
                                                                                               Hierarchical ID
15.0    2000A                                                                          HL01                          R AN 1/12 data segment in a hierarchical structure.                       HL01 would be '1' for the initial
                                                                                               Number
                                                                                                                                                                                               HL segment and would be
                                                                                                                                                                                               incremented by 1 for each
                                                                                                                                                                                               subsequent HL segment within
                                                                                                                                                                                               the transaction.


                                                                                                                                                                                                       HL03 indicates the context of
                                                                                                                                  Code defining the characteristic of a level in a hierarchical        the series of segments following
                                                                                               Hierarchical Level
16.0    2000A                                                                          HL03                          R   ID   1/2 structure.                                                           the current HL segment up to
                                                                                               Code
                                                                                                                                  Set to '20' - Information Source                                     the next occurrence of an HL
                                                                                                                                                                                                       segment in the transaction.

                                                                                                                                    Code indicating if there are hierarchical child data segments
                                                                                               Hierarchical Child                   subordinate to the level being described.
17.0    2000A                                                                          HL04                          R   ID   1/1
                                                                                               Code                                 Set to '1' - Additional Subordinate HL Data Segment in this
                                                                                                                                    Hierarchical Structure.
        2100A -
        Loop
18.0              Payer Name                  1                                                                                                                                                                                                                                                                                    This will contain MAD information.
        Within
        2000A
                                                                                                                                    Payers with multiple locations or multiple lines of business may
19.0    2100A                                       0500 NM1   Payer Name      R   1
                                                                                                                                    require that the payer name be completed.
                                                                                               Entity Identifier
20.0    2100A                                                                          NM101                         R   ID   2/3 Set to 'PR' - Payer
                                                                                               Code
                                                                                               Entity Type
21.0    2100A                                                                          NM102                         R   ID   1/1 Set to '2' - Non-Person Entity
                                                                                               Qualifier
22.0    2100A                                                                          NM103   Payer Name            R AN 1/60
                                                                                                                               Code designating the system/method of code structure used for
                                                                                               Identification Code             NM109.
23.0    2100A                                                                          NM108                         R   ID   1/2
                                                                                               Qualifier                       Set to 'PI' - Payer Identification, until 'XV' - HCFA National Plan
                                                                                                                               ID is required.
24.0    2100A                                                                          NM109   Payer Identifier      R AN 2/80 Set to 'NM Medical Assistance'

                                                                                                                                    Required when the payer's contact information is not otherwise
                                                                                                                                    specified in a trading partner agreement and the information
                                                               Payer Contact
25.0    2100A                                       0800 PER                   S   1                                                receiver does not know how to contact the payer. If not
                                                               Information
                                                                                                                                    required by this implementation guide, may be provided at the
                                                                                                                                    sender's discretion, but cannot be required by the receiver.

                                                                                               Contact Function                     Code identifying the major duty or responsibility of the person
26.0    2100A                                                                          PER01                         R   ID   2/2
                                                                                               Code                                 or group named. Set to 'IC' - Information Contact.

                                                                                                                               Payer Contact Name - Free-form name.
                                                                                                                               This element is required when a specific person or department
                                                                                                                               is the contact for the response in order to clarify requests
27.0    2100A                                                                          PER02   Name                  S AN 1/60
                                                                                                                               concerning additional information requests.
                                                                                                                               Set to 'ACS Provider Relations'




                                                                                                                                                                    Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                   Page: 2 of 17                                                                                                                                                       November 30, 2009
                                                                                                                                                                                                                                                                                                                  New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                Business Rules Comparion
                                                                                                                                                                                                                                                                                                                    277 Health Care Claim Status Response




                                                                                          ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                     MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                      N
                                                                                                                                  Code identifying the type of communication number in PER04.
                                                                                                                                  Values are:
                                                                                                                                  'ED' - Electronic Data Interchange Access Number
                                                                                               Communication
28.0    2100A                                                                          PER03                         R   ID   2/2 'EM' - Electronic Mail
                                                                                               Number Qualifier
                                                                                                                                  'TE' - Telephone
                                                                                                                                  'FX' - Fax.
                                                                                                                                  Set to 'TE'


                                                                                               Payer Contact                    Complete communications number including country or area
                                                                                               Communication                    code when applicable. Use PER04 to supply International
29.0    2100A                                                                          PER04   Number                R AN 1/256 Codes, Area Code (within US), Local exchanges and telephone
                                                                                               (Communication                   numbers. Use PER06 when an add'l extension is required.
                                                                                               Number)                          Set to '1-800-299-7304'

                                                                                               Communication
30.0    2100A                                                                          PER05                         S   ID   2/2 Set to 'EX' - Telephone Extension                                                                                                                                                    Do not send.
                                                                                               Number Qualifier
                                                                                               Communication
31.0    2100A                                                                          PER06                         S AN 1/256 Use PER06 to supply telephone extensions only.                                                                                                                                         Do not send.
                                                                                               Number
                                                                                                                                  Required when PER08 is used since this describes what is in
                                                                                                                                  PER08.
                                                                                                                                  Values are:
                                                                                               Communication                      'ED' - Electronic Data Interchange Access Number
32.0    2100A                                                                          PER07                         S   ID   2/2                                                                                                                                                                                      Do not send.
                                                                                               Number Qualifier                   'EM' - Electronic Mail
                                                                                                                                  'TE' - Telephone
                                                                                                                                  'EX' - Telephone Extension
                                                                                                                                  'FX' - Facsimile
                                                                                               Payer Contact
                                                                                               Communication
                                                                                                                                    Required when necessary to provide another telephone
33.0    2100A                                                                          PER08   Number                S AN 1/256                                                                                                                                                                                        Do not send.
                                                                                                                                    extension or fax number.
                                                                                               (Communication
                                                                                               Number)
                  Table 2 - Detail,
34.0    2000B     Information Receiver >1
                  Level
                                                              Information
35.0    2000B                                       0100 HL                    R   1                                                Information Receiver
                                                              Receiver Level

                                                                                                                                                                                               HL01 shall contain a unique
                                                                                                                               A unique number assigned by the sender to identify a particular
                                                                                               Hierarchical ID                                                                                 alphanumeric number for each
36.0    2000B                                                                          HL01                          R AN 1/12 data segment in a hierarchical structure.
                                                                                               Number                                                                                          occurrence of the HL segment
                                                                                                                                                                                               in the transaction set.

                                                                                               Hierarchical Parent                  HL02 identifies the hierarchical ID number of the HL segment
37.0    2000B                                                                          HL02                          R AN 1/12
                                                                                               ID Number                            to which the current HL segment is subordinate.
                                                                                                                                    HL03 indicates the context of the series of segments following
                                                                                               Hierarchical Level                   the current HL segment up to the next occurrence of an HL
38.0    2000B                                                                          HL03                          R   ID   1/2
                                                                                               Code                                 segment in the transaction.
                                                                                                                                    Set to '21' - Information Receiver.
                                                                                                                                    HL04 indicates whether or not there are subordinate HL
                                                                                               Hierarchical Child                   segments related to the current HL segment.
39.0    2000B                                                                          HL04                          R   ID   1/1
                                                                                               Code                                 Set to '1' - Additional Subordinate HL Data Segment in this
                                                                                                                                    Hierarchical Structure.
        2100B -
        Within    Information Receiver                                                                                              This is the individual or organization requesting to receive the
40.0                                          1
        Loop      Name                                                                                                              status information.
        2000B




                                                                                                                                                                     Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                    Page: 3 of 17                                                                                                                                     November 30, 2009
                                                                                                                                                                                                                                                                                                                New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                              Business Rules Comparion
                                                                                                                                                                                                                                                                                                                  277 Health Care Claim Status Response




                                                                                           ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                  MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                           N
                                                              Information                                                                                                                                                                                                                                            Format from 276 request, loop 2100B, NM1
41.0    2100B                                      0500 NM1                    R   1
                                                              Receiver Name                                                                                                                                                                                                                                          Information Receiver segment
                                                                                                                                     Code identifying an organizational entity, a physical location,
                                                                                                  Entity Identifier
42.0    2100B                                                                           NM101                           R   ID   2/3 property or an individual.
                                                                                                  Code
                                                                                                                                     Set to '41' - Submitter
                                                                                                                                       Code qualifying the type of entity.
                                                                                                  Entity Type                          Values are:
43.0    2100B                                                                           NM102                           R   ID   1/1
                                                                                                  Qualifier                            '1' - Person
                                                                                                                                       '2' - Non-Person Entity

                                                                                                  Information
44.0    2100B                                                                           NM103     Receiver Last or      R AN 1/60
                                                                                                  Organization Name

                                                                                                  Information
                                                                                                                                       This is required when the value in NM102 is '1' and the person
45.0    2100B                                                                           NM104     Receiver First        S AN 1/35
                                                                                                                                       has a first name.
                                                                                                  Name
                                                                                                  Information                     Required if add'l name information is needed to identify the
46.0    2100B                                                                           NM105     Receiver Middle       S AN 1/25 information receiver. Recommended if the value in the entity
                                                                                                  Name                            type qualifier is a person.
                                                                                                                                       Code designating the system/method of code structure used for
                                                                                                  Identification Code                  NM109.
47.0    2100B                                                                           NM108                           R   ID   1/2
                                                                                                  Qualifier                            Values are:
                                                                                                                                       '46' - Electronic Transmitter Identification Number (ETIN)
                                                                                                  Information
                                                                                                  Receiver
48.0    2100B                                                                           NM109                           R AN 2/80 ETIN is established through the TPA.
                                                                                                  Identification
                                                                                                  Number
                                                                                                                                       Required when rejecting claim status requests for errors at
                                                              Information
                                                                                                                                       Information Source or Information Receiver levels. If not
49.0    2200B                                      0900 TRN   Receiver Trace   S   1
                                                                                                                                       required, do not send. When reporting error status at this level,
                                                              Identifier
                                                                                                                                       2000C, 2000D, and 2000E loops are not used.
                                                                                                                                  Code identifying which transaction is being referenced.
50.0    2200B                                                                           TRN01     Trace Type Code       R   ID   1/2
                                                                                                                                  Set to '2' - Referenced Transaction Trace Numbers.
                                                                                                                                  Provides unique identification for the transaction. Must be the
                                                                                                  Claim Transaction
51.0    2200B                                                                           TRN02                           R AN 1/50 BHT03 data element value from the 276 transaction being                                                                                                                            Format from request, header loop, BHT03 element
                                                                                                  Batch Number
                                                                                                                                  rejected
                                                                                                                                       Allows the capability to report a rejected status for the entire
                                                                                                                                       276 transaction for errors at the information source or
                                                              Claim Level
                                                                                                                                       information receiver levels. Status at this level is the result of
52.0    2200B                                      1000 STC   Status           R   >1
                                                                                                                                       system or application availability, transaction size limitations for
                                                              Information
                                                                                                                                       real time capability or Trading Partner authorization/verification
                                                                                                                                       issues.

                                                                                                  Health Claim Care                    Used to convey status of the entire claim or a specific service
53.0    2200B                                                                           STC01                           R
                                                                                                  Status                               line. Only D0 or E category codes are allowable at this level.

                                                                                                  Health Care Claim
                                                                                                                                                                                                                                                                                                                     Set to 'E0' if there is an error on the submitted
54.0    2200B                                                                           STC01-1   Status Category       R AN 1/30 This is the category code. Use code source 507
                                                                                                                                                                                                                                                                                                                     request, or 'E1' if the system is down.
                                                                                                  Code
                                                                                                  Health Care Claim                                                                                                                                                                                                  Will need to determine the appropriate status code
55.0    2200B                                                                           SCT01-2                         R AN 1/30 This is the Status code. Use code source 508.
                                                                                                  Status Code                                                                                                                                                                                                        during detail design
                                                                                                                                     Required when an entity must be identified to further clarify the
                                                                                                                                     code message in STC01-2. Valid codes are:
                                                                                                  Entity Identifier
56.0    2200B                                                                           STC01-3                         S   ID   2/3 '41' - Submitter
                                                                                                  Code
                                                                                                                                     'AY' - Clearinghouse
                                                                                                                                     'PR' - Payer




                                                                                                                                                                         Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                        Page: 4 of 17                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                   New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                 Business Rules Comparion
                                                                                                                                                                                                                                                                                                                     277 Health Care Claim Status Response




                                                                                                ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                MMIS SPECIFICATIONS




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                                                                                                       Status Information                   Format is CCYYMMDD. Use this date for the effective date of
57.0    2200B                                                                                STC02                           R DT 8/8                                                                                                                                                                                   Set to current date.
                                                                                                       Effective Date                       status.
                                                                                                       Health Care Claim
58.0    2200B                                                                                STC10                           S              Use this element if a second claim status Is needed
                                                                                                       Status
                                                                                                       Health Care Claim
                                                                                                                                            This is the category code. Use code source 507.
59.0    2200B                                                                                STC10-1   Status Category       S AN 1/30
                                                                                                                                            Required if STC10 is used.
                                                                                                       Code
                                                                                                       Health Care Claim                    This is the Status code. Use code source 508.
60.0    2200B                                                                                SCT10-2                         S AN 1/30
                                                                                                       Status Code                          Required if STC10 is used.
                                                                                                                                          This further modifies the status code in STC10-2.
                                                                                                                                          Valid codes are:
                                                                                                       Entity Identifier
61.0    2200B                                                                                STC10-3                         S   ID   2/3 '41' - Submitter
                                                                                                       Code
                                                                                                                                          'AY' - Clearinghouse
                                                                                                                                          'PR' - Payer
                                                                                                       Health Care Claim
62.0    2200B                                                                                STC11                           S              Use this element is a third claim status is needed
                                                                                                       Status
                                                                                                       Health Care Claim
                                                                                                                                            This is the category code. Use code source 507.
63.0    2200B                                                                                STC11-1   Status Category       S AN 1/30
                                                                                                                                            Required if STC11 is used.
                                                                                                       Code
                                                                                                       Health Care Claim                    This is the Status code. Use code source 508.
64.0    2200B                                                                                SCT11-2                         S AN 1/30
                                                                                                       Status Code                          Required if STC11 is used.
                                                                                                                                          This further modifies the status code in STC11-2.
                                                                                                                                          Valid codes are:
                                                                                                       Entity Identifier
65.0    2200B                                                                                STC11-3                         S   ID   2/3 '41' - Submitter
                                                                                                       Code
                                                                                                                                          'AY' - Clearinghouse
                                                                                                                                          'PR' - Payer
                  Table 2 - Detail,
66.0    2000C     Service Provider          >1
                  Level
                                                                  Service Provider                                                          To identify dependencies among and the content of
67.0    2000C                                          0100 HL                       R   1
                                                                  Level                                                                     hierarchically related groups of data segments.

                                                                                                                                            A unique number assigned by the sender to identify a particular
                                                                                                       Hierarchical ID                      data segment in a hierarchical structure.
68.0    2000C                                                                                HL01                            R AN 1/12
                                                                                                       Number                               HL01 shall contain a unique alphanumeric number for each
                                                                                                                                            occurrence of the HL segment in the transaction set.

                                                                                                       Hierarchical Parent                  HL02 identifies the hierarchical ID number of the HL segment
69.0    2000C                                                                                HL02                            R AN 1/12
                                                                                                       ID Number                            to which the current HL segment is subordinate.
                                                                                                                                            HL03 indicates the context of the series of segments following
                                                                                                       Hierarchical Level                   the current HL segment up to the next occurrence of an HL
70.0    2000C                                                                                HL03                            R   ID   1/2
                                                                                                       Code                                 segment in the transaction.
                                                                                                                                            Set to '19' - Provider of Service
                                                                                                                                            HL04 indicates whether or not there are subordinate HL                                                                                                                      Could also be '0' when rejecting the status request
                                                                                                       Hierarchical Child                   segments related to the current HL segment.                                                                                                                                 for errors at the Information Source or Receiver
71.0    2000C                                                                                HL04                            R   ID   1/1
                                                                                                       Code                                 Set to '1' - Additional Subordinate HL Data Segment in this                                                                                                                 Levels p125 of IG. Would Translator take care of
                                                                                                                                            Hierarchical Structure.                                                                                                                                                     this?
        2100C -
        Within
72.0              Provider Name                  2
        Loop
        2000C
                                                                                                                                            After the transition to NPI, for thus health care providers
                                                                                                                                            covered under the NPI mandate, only one iteration of the
73.0    2100C                                          0500 NM1   Provider Name      R   2
                                                                                                                                            2100C loop must be sent with the NPI reported in the NM109
                                                                                                                                            and NM108 = 'XX'




                                                                                                                                                                            Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                           Page: 5 of 17                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                                       New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                     Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                         277 Health Care Claim Status Response




                                                                                          ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                                    MMIS SPECIFICATIONS




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                                                                                                                                    Code identifying an organizational entity, a physical location,
                                                                                                 Entity Identifier
74.0    2100C                                                                          NM101                           R   ID   2/3 property or an individual.
                                                                                                 Code
                                                                                                                                    Set to '1P' - Provider
                                                                                                                                      Code qualifying the type of entity.
                                                                                                 Entity Type                          Values are:
75.0    2100C                                                                          NM102                           R   ID   1/1
                                                                                                 Qualifier                            '1' - Person
                                                                                                                                      '2' - Non-Person Entity
                                                                                                                                      Required when the identifier in NM109 is not sufficient to
                                                                                                 Provider Last or                     identify the provider. If not required by this implementation
76.0    2100C                                                                          NM103                           R AN 1/60                                                                                           P_PROV_TB                 P-NAM               X(35)        1589      Provider Name
                                                                                                 Organization Name                    guide, may be provided at sender's discretion, but cannot be
                                                                                                                                      required by the receiver.
                                                                                                                                                                                                                                                                                                Provider Last
77.0    2100C                                                                                                                                                                                                              P_PROV_TB                 P-LAST-NAM          X(35)        1160
                                                                                                                                                                                                                                                                                                Name
                                                                                                                                 This is required when the value in NM102 is '1' and the person                                                                                                 Provider First
78.0    2100C                                                                          NM104     Provider First Name S AN 1/35                                                                                             P_PROV_TB                 P-FST-NAM           X(15)        8684
                                                                                                                                 has a first name.                                                                                                                                              Name
                                                                                                 Provider Middle                 Required when the value in NM102 is '1' and the person has a                                                                                                   Provider Middle
79.0    2100C                                                                          NM105                           S AN 1/25                                                                                           P_PROV_TB                 P-MI-NAM            X(01)        5642
                                                                                                 Name                            middle name or initial.                                                                                                                                        Initial
                                                                                                                                 Required if add'l name information is needed to identify the
                                                                                                 Provider Name
80.0    2100C                                                                          NM107                           S AN 1/10 information receiver. Recommended if the value in the entity                              P_PROV_TB                 P-SFX-NAM           X(10)            519   Provider Suffix
                                                                                                 Suffix
                                                                                                                                 type qualifier is a person.

                                                                                                                                    Code designating the system/method of code structure used for
                                                                                                                                    NM109.
                                                                                                                                    Values are:
                                                                                                                                    'FI' - Federal Taxpayer's Identification Number
                                                                                                 Identification Code                                                                                                                                                                                               National Provider
81.0    2100C                                                                          NM108                           R   ID   1/2 'SV' - Service Provider Number. When the provider does not                                                       P-NPI-ID            X(10)            399   NPI
                                                                                                 Qualifier                                                                                                                                                                                                         Identifier
                                                                                                                                    have a National Provider ID and the Payer has assigned a
                                                                                                                                    specific ID number to this provider this code is required.
                                                                                                                                    'XX' - HCFA National Provider ID. Required value if the
                                                                                                                                    National Provider ID is mandated for use.

                                                                                                                                                                                                                                                                                                                   National Provider
82.0    2100C                                                                          NM109     Provider Identifier   R AN 2/80                                                                                           C_HDR_TB                  P-NPI-ID            X(10)            399   NPI
                                                                                                                                                                                                                                                                                                                   Identifier
                                                                                                                                                                                                                                                                                                                   The NM MMIS
83.0    2100C                                                                                                                                                                                                              C_HDR_TB                  C-BLNG-PROV-ID      X(08)        1011      Billing Provider
                                                                                                                                                                                                                                                                                                                   provider id
                                                                                                                                                                                                                                                                                                                   The NM MMIS
84.0    2100C                                                                                                                                                                                                              C_HDR_TB                  C-BLNG-TAX-ID       X(09)        1381      Billing Provider
                                                                                                                                                                                                                                                                                                                   provider id
                                                                                                                                      Required when rejecting claim status requests for errors at
                                                              Provider of
                                                                                                                                      provider level. If not required, do not send. When reporting
85.0    2200C                                      0900 TRN   Service Trace   S   1
                                                                                                                                      error status at this level, 2000D, and 2000E loops are not
                                                              Identifier
                                                                                                                                      used.
                                                                                                                                      Code identifying which transaction is being referenced.
86.0    2200C                                                                          TRN01     Trace Type Code       R   ID   1/2
                                                                                                                                      Set to '1' - Current Transaction Trace Numbers.
                                                                                                 Claim Transaction                                                                                                                                                                                                                          Populate from 276 request, header loop, BHT03
87.0    2200C                                                                          TRN02                           R AN 1/50 Set to zero.
                                                                                                 Batch Number                                                                                                                                                                                                                               element
                                                                                                                                      Allows the capability to report a rejected status for the entire
                                                              Claim Level
                                                                                                                                      276 transaction for errors at the provider level. Status at this
88.0    2200C                                      1000 STC   Status          R   >1
                                                                                                                                      level is typically the result of provider authorization/verification
                                                              Information
                                                                                                                                      issues.

                                                                                                 Health Claim Care                    Used to convey status of the entire claim or a specific service
89.0    2200C                                                                          STC01                           R
                                                                                                 Status                               line. Only D0 or E category codes are allowable at this level.

                                                                                                 Health Care Claim                                                                                                                                                                                                                          Set to 'E0' - there is an error on the submitted
90.0    2200C                                                                          STC01-1   Status Category       R AN 1/30 This is the category code. Use code source 507                                                                                                                                                             request - if requesting provider cannot be found
                                                                                                 Code                                                                                                                                                                                                                                       on the MMIS.




                                                                                                                                                                        Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                       Page: 6 of 17                                                                                                                                                            November 30, 2009
                                                                                                                                                                                                                                                                                                                   New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                 Business Rules Comparion
                                                                                                                                                                                                                                                                                                                     277 Health Care Claim Status Response




                                                                                                ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                MMIS SPECIFICATIONS




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                                                                                                       Health Care Claim                                                                                                                                                                                                Will need to determine during detail design the
91.0    2200C                                                                                SCT01-2                         R AN 1/30 This is the Status code. Use code source 508.
                                                                                                       Status Code                                                                                                                                                                                                      appropriate status code
                                                                                                                                      Required when an entity must be identified to further clarify the
                                                                                                       Entity Identifier
92.0    2200C                                                                                STC01-3                         S    2/3 code message in STC01-2. Valid codes are:
                                                                                                                                 ID
                                                                                                       Code
                                                                                                                                      '1P' - Provider
                                                                                                       Status Information             Format is CCYYMMDD. Use this date for the effective date of
93.0    2200C                                                                                STC02                           R DT 8/8                                                                                                                                                                                   Set to current date.
                                                                                                       Effective Date                 status.
                                                                                                       Health Care Claim
94.0    2200C                                                                                STC10                           S              Use this element if a second claim status Is needed
                                                                                                       Status
                                                                                                       Health Care Claim
                                                                                                                                            This is the category code. Use code source 507.
95.0    2200C                                                                                STC10-1   Status Category       S AN 1/30
                                                                                                                                            Required if STC10 is used.
                                                                                                       Code
                                                                                                       Health Care Claim                  This is the Status code. Use code source 508.
96.0    2200C                                                                                SCT10-2                         S AN 1/30
                                                                                                       Status Code                        Required if STC10 is used.
                                                                                                                                          This further modifies the status code in STC10-2.
                                                                                                       Entity Identifier
97.0    2200C                                                                                STC10-3                         S   ID   2/3 Valid codes are:
                                                                                                       Code
                                                                                                                                          '1P' - Provider
                                                                                                       Health Care Claim
98.0    2200C                                                                                STC11                           S              Use this element is a third claim status is needed
                                                                                                       Status
                                                                                                       Health Care Claim
                                                                                                                                            This is the category code. Use code source 507.
99.0    2200C                                                                                STC11-1   Status Category       S AN 1/30
                                                                                                                                            Required if STC11 is used.
                                                                                                       Code
                                                                                                       Health Care Claim                  This is the Status code. Use code source 508.
100.0   2200C                                                                                SCT11-2                         S AN 1/30
                                                                                                       Status Code                        Required if STC11 is used.
                                                                                                                                          This further modifies the status code in STC11-2.
                                                                                                       Entity Identifier
101.0   2200C                                                                                STC11-3                         S   ID   2/3 Valid codes are:
                                                                                                       Code
                                                                                                                                          '1P' - Provider
                  Table 2 - Detail,
102.0   2000D                               >1
                  Subscriber Level
                                                                                                                                            To identify dependencies among and the content of
103.0   2000D                                          0100 HL    Subscriber Level   R   1
                                                                                                                                            hierarchically related groups of data segments.

                                                                                                                                            A unique number assigned by the sender to identify a particular
                                                                                                       Hierarchical ID                      data segment in a hierarchical structure.
104.0   2000D                                                                                HL01                            R AN 1/12
                                                                                                       Number                               HL01 shall contain a unique alphanumeric number for each
                                                                                                                                            occurrence of the HL segment in the transaction set.

                                                                                                       Hierarchical Parent                  HL02 identifies the hierarchical ID number of the HL segment
105.0   2000D                                                                                HL02                            R AN 1/12
                                                                                                       ID Number                            to which the current HL segment is subordinate.
                                                                                                                                            HL03 indicates the context of the series of segments following
                                                                                                       Hierarchical Level                   the current HL segment up to the next occurrence of an HL
106.0   2000D                                                                                HL03                            R   ID   1/2
                                                                                                       Code                                 segment in the transaction.
                                                                                                                                            Set to '22' - Subscriber
                                                                                                                                          HL04 indicates whether or not there are subordinate HL
                                                                                                                                          segments related to the current HL segment.
                                                                                                       Hierarchical Child
107.0   2000D                                                                                HL04                            R   ID   1/1 Set to '0' - No Subordinate HL Segment in this Hierarchical
                                                                                                       Code
                                                                                                                                          Structure. Required when there are no dependent claim status
                                                                                                                                          requests for this subscriber.
        2100D -
        Within
108.0             Subscriber Name                1
        Loop
        2000D
                                                                  Subscriber
109.0   2100D                                          0500 NM1                      R   1                                                  Subscriber Name
                                                                  Name




                                                                                                                                                                            Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                           Page: 7 of 17                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                                    New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                  Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                      277 Health Care Claim Status Response




                                                                                            ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                               MMIS SPECIFICATIONS




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                                                                                                                                    Code identifying an organizational entity, a physical location,
                                                                                                 Entity Identifier
110.0   2100D                                                                            NM101                         R   ID   2/3 property or an individual.
                                                                                                 Code
                                                                                                                                    Set to 'IL' - Insured or subscriber
                                                                                                 Entity Type                        Code qualifying the type of entity.
111.0   2100D                                                                            NM102                         R   ID   1/1
                                                                                                 Qualifier                          Set to '1' - Person
                                                                                                                                                                                                                                                                                                               This is the Client's
                                                                                                 Subscriber Last                                                                                                                                                                             Client's Last
112.0   2100D                                                                            NM103                         R AN 1/60 Subscriber last name                                                                    C_HDR_TB                 B-LAST-NAM          X(21)            639                     surname or family
                                                                                                 Name                                                                                                                                                                                        Name
                                                                                                                                                                                                                                                                                                               name.
                                                                                                                                                                                                                                                                                                               This is the Client's
                                                                                                 Subscriber First                     The first name is required when the value in NM102 is '1' and                                                                                          Client's First
113.0   2100D                                                                            NM104                         R AN 1/35                                                                                         C_HDR_TB                 B-FST-NAM           X(15)            637                     given name or first
                                                                                                 Name                                 the person has a first name.                                                                                                                           Name
                                                                                                                                                                                                                                                                                                               name.
                                                                                                                                                                                                                                                                                                               This is the first letter
                                                                                                 Subscriber Middle                    Subscriber middle name or initial is required when the value in                                                                                        Client's Middle
114.0   2100D                                                                            NM105                         R AN 1/25                                                                                         C_HDR_TB                 B-MI-NAM            X                640                     of the Client's Middle
                                                                                                 Name                                 NM102 is '1' and the person has a middle name or initial.                                                                                              Initial
                                                                                                                                                                                                                                                                                                               Name.
                                                                                                                                 Required if additional name information is needed to identify
                                                                                                 Subscriber Name                                                                                                                                                                             Client Suffix     This is the Client's
115.0   2100D                                                                            NM107                         S AN 1/10 the subscriber. Recommended if the value in the entity type                             B_DETAIL_TB              B-SFX-NAM           X(03)        3599                                             Not on claim, however this is Situational.
                                                                                                 Suffix                                                                                                                                                                                      Name              name Suffix. ie, JR.
                                                                                                                                 qualifier is a person.

                                                                                                                                    Code designating the system/method of code structure used for
                                                                                                                                    NM109.
                                                                                                                                    Values are:
                                                                                                 Identification Code
116.0   2100D                                                                            NM108                         R   ID   1/2 '24' - Employer's Identification Number
                                                                                                 Qualifier
                                                                                                                                    'MI' - Member Identification Number
                                                                                                                                    'II' - Standard Unique Health Identifier for each individual in the
                                                                                                                                    US.                                                   Set to 'MI'.


                                                                                                                                                                                                                                                                                                               B-CURR-ID: This is         B-CURR-ID will be sent in this field since this is
                                                                                                                                                                                                                                                                                             Current Client    the client id by which     the id that the Provider should know the
117.0   2100D                                                                            NM109   Subscriber Identifier R AN 2/80 Subscriber identifier described by NM108.                                               C_HDR_TB                 B-CURR-ID           X(14)        8688
                                                                                                                                                                                                                                                                                             ID                the Client is known        Subscriber by even though it could change
                                                                                                                                                                                                                                                                                                               to the State.              monthly.


                                                                                                                                                                                                                                                                                                                B-ALT-ID: This is the
                                                                                                                                                                                                                                                                                                                client id by which the
                                                                                                                                                                                                                                                                                                                                       This could have been a previous id this Client was
118.0                                                                                                                                                                                                                    C_HDR_TB                 B-ALT-ID            X(14)            535   Client ID for elig Client is known to
                                                                                                                                                                                                                                                                                                                                       known by.
                                                                                                                                                                                                                                                                                                                the State. A kind of
                                                                                                                                                                                                                                                                                                                'also known as' ID.


                                                                                                                                                                                                                                                                                                               B-SYS-ID: System
                                                                                                                                                                                                                                                                      S9(09)                 Client System                                This ID never changes but is currently not known
119.0                                                                                                                                                                                                                    C_HDR_TB                 B-SYS-ID                             694                     generated Client
                                                                                                                                                                                                                                                                      comp                   ID                                           by the client.
                                                                                                                                                                                                                                                                                                               cross reference ID.

        2200D -
        Within    Claim Submitter
120.0                                         >1
        Loop      Trace Number
        2000D

                                                                                                                                      Required when the patient is the subscriber or a dependent
                                                               Claim Submitter                                                        with a unique identification number.
121.0   2200D                                       0900 TRN                     R   1
                                                               Trace Number                                                           This is the trace or reference number from the originator of the
                                                                                                                                      transaction that was provided for this patient's 276 request.

                                                                                                                                      Code identifying which transaction is being referenced.
122.0   2200D                                                                            TRN01   Trace Type Code       R   ID   1/2
                                                                                                                                      Set to '2' - Referenced Transaction Trace Numbers.
                                                                                                                                                                                                                                                                                                                                          Populate from 276 request, Claim Submitter Trace
123.0   2200D                                                                            TRN02   Trace Number          R AN 1/50 Provides unique identification for the transaction.
                                                                                                                                                                                                                                                                                                                                          Number loop 2200D, TRN02 element




                                                                                                                                                                      Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                     Page: 8 of 17                                                                                                                                                             November 30, 2009
                                                                                                                                                                                                                                                                                                                             New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                           Business Rules Comparion
                                                                                                                                                                                                                                                                                                                               277 Health Care Claim Status Response




                                                                                       ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                               MMIS SPECIFICATIONS




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                                                              Claim Level
                                                                                                                                   This is required if the subscriber is the patient.
124.0   2200D                                      1000 STC   Status        R   1
                                                                                                                                   Claim Status information in response to solicited inquiry.
                                                              Information
                                                                                              Health Claim Care                    Used to convey status of the entire claim or a specific service
125.0   2200D                                                                       STC01                           R
                                                                                              Status                               line.

                                                                                              Health Care Claim                                                                                                                                                                                          A code that indicates
                                                                                                                                                                                                                                                                                                                               Crosswalk MMIS status codes to the Health Care
126.0   2200D                                                                       STC01-1   Status Category       R AN 1/30 This is the category code. Use code source 507                                          C_HDR_TB                 C-HDR-STAT-CD     X(01)        1020      Status Code      the current status of
                                                                                                                                                                                                                                                                                                                               Claim Status Category Codes.
                                                                                              Code                                                                                                                                                                                                       the claim.

                                                                                                                                                                                                                                                                                                         A code that indicates Crosswalk MMIS status codes and header level
                                                                                              Health Care Claim
127.0   2200D                                                                       SCT01-2                         R AN 1/30 This is the Status code. Use code source 508.                                           C_HDR_TB                 C-HDR-STAT-CD     X(01)        1020      Status Code      the current status of exception codes to the Health Care Claim Status
                                                                                              Status Code
                                                                                                                                                                                                                                                                                                         the claim.            Codes.

                                                                                                                                                                                                                                                                                                        Indicates the code
                                                                                                                                                                                                                                                                                        Claim Exception
128.0   2200D                                                                                                                                                                                                         X_LI_EXC_TB              R-CLM-EXC-CD      X(04)        1737                      (number) of the
                                                                                                                                                                                                                                                                                        Code
                                                                                                                                                                                                                                                                                                        claim exception
                                                                                                                                 Required when an entity must be identified to further clarify the
                                                                                                                                 status code in STC01-2. Required if add'l detail applicable to
                                                                                                                                 claim status is needed to clarify the status and the payer's
                                                                                                                                                                                                                                                                                                                                  Don't believe this is necessary, but need to
                                                                                                                                 system supports this level of detail.
                                                                                                                                                                                                                                                                                                                                  examine the possible header level exception
                                                                                              Entity Identifier                  See Implementation Guide for valid codes, too numerous to list
129.0   2200D                                                                       STC01-3                         S   ID   2/3                                                                                                                                                                                                  codes and how they crosswalk to the Health Care
                                                                                              Code                               here. Examples are:
                                                                                                                                                                                                                                                                                                                                  Claim Status Codes to determine if there are any
                                                                                                                                 '13' - Contracted Service Provider
                                                                                                                                                                                                                                                                                                                                  situations where we need to populate this field.
                                                                                                                                 '17' - Consultant's Office
                                                                                                                                 '1E' - HMO
                                                                                                                                 '1G' - Oncology Center
                                                                                                                                   Required when using NCPDP reject/payment code in STC01-2
                                                                                                                                                                                                                                                                                                                                  Will not be generated. The MMIS keeps internal
                                                                                              Code List Qualifier                  for status related to a pharmacy claim. If not required by this
130.0   2200D                                                                       STC01-4                         S   ID   1/3                                                                                                                                                                                                  MMIS reject/payment status codes, not NCPDP
                                                                                              Code                                 IG, do not send.
                                                                                                                                                                                                                                                                                                                                  codes.
                                                                                                                                   Value is 'RX' - NCPDP Reject/Payment Codes

                                                                                                                                                                                                                                                                                                         The date the claim
                                                                                              Status Information                   Format is CCYYMMDD. Use this date for the effective date of                                                                                          Adjudication     was last processed
131.0   2200D                                                                       STC02                           R DT 8/8                                                                                          C_HDR_TB                 C-HDR-ADJUD-DT    X(10)            963
                                                                                              Effective Date                       status.                                                                                                                                              Date             by the adjudication
                                                                                                                                                                                                                                                                                                         program.

                                                                                                                                  Use this element for the amount of submitted charges. Some
                                                                                              Total Claim Charge                                                                                                                                                 S9(09)V99                               Sum of the claims
132.0   2200D                                                                       STC04                           R   R    1/18 HMO encounters supply zero as the amount of original                                C_HDR_TB                 C-TOT-CHRG-AMT                 1025      Total Charge
                                                                                              Amount                                                                                                                                                             COMP-3                                  billed charges
                                                                                                                                  charges.
                                                                                                                                                                                                                                                                                                      The final
                                                                                                                                  Use this element for the claim paid amount. This amount                                                                                                             reimbursement
                                                                                                                                  should be 0 if the adjudication process in not complete. Claim                                                                                                      amount for the claim.
                                                                                              Claim Payment                       total charge will quite often change from the submitted claim                                                                  S9(09)V99              Total         Computed as
133.0   2200D                                                                       STC05                           R   R    1/18                                                                                     C_HDR_TB                 C-TOT-REIMB-AMT                1028
                                                                                              Amount                              total charge based on claims processing instructions, ie,                                                                      COMP-3                 Reimbursement calculated allowed
                                                                                                                                  splitting claims. Most payers do not store the 'original                                                                                                            charge plus/minus
                                                                                                                                  submitted charge'.                                                                                                                                                  all base rate
                                                                                                                                                                                                                                                                                                      changes.

                                                                                                                                                                                                                                                                                                         The date the claim
                                                                                                                               Format is CCYYMMDD. Use this element for the date of denial
                                                                                              Adjudication                                                                                                                                                                                               was last processed
134.0   2200D                                                                       STC06                           S   DT 8/8 or payment. Use this date if the payment determination is                              C_HDR_TB                 C-HDR-PD-DT       X(10)        1017      Payment Date
                                                                                              Finalized Date                                                                                                                                                                                             by the adjudication
                                                                                                                               complete.
                                                                                                                                                                                                                                                                                                         program.




                                                                                                                                                                   Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                  Page: 9 of 17                                                                                                                                                       November 30, 2009
                                                                                                                                                                                                                                                                                                                    New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                  Business Rules Comparion
                                                                                                                                                                                                                                                                                                                      277 Health Care Claim Status Response




                                                                                ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                             MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                             N
                                                                                                                                                                                                                                                                                                This field contains
                                                                                                                                                                                                                                                                                                the date the claim
                                                                                                                                                                                                                                                                                                was paid. The date
                                                                                                                          Use this element for the check issue date or for the date that                                                                                                        is taken from a
135.0   2200D                                                                STC08     Remittance Date       S   DT 8/8                                                                                      C_HDR_TB                 C-HDR-PD-DT       X(10)        1017     Paid Date
                                                                                                                          EFT funds were released to the ACH.                                                                                                                                   system parm and
                                                                                                                                                                                                                                                                                                represents the date
                                                                                                                                                                                                                                                                                                printed on the
                                                                                                                                                                                                                                                                                                Warrant.


                                                                                                                                                                                                                                                                                             Warrant number that
                                                                                                                          Required with a Finalized and Paid claim when the entire claim
                                                                                                                                                                                                                                                                                             uniquely identifies a
                                                                                       Check or EFT                       was paid using a single check or FT. Not used with Pending or                                                                                       Claims Check                         Claim will be paid either with a warrant or through
136.0   2200D                                                                STC09                           S AN 1/16                                                                                       C_HDR_WARRANT_TB         C-HDR-WARR-NUM X(11)           1041                    payment to a
                                                                                       Trace Number                       Rejected claims. If the payment is EFT, this number is the                                                                                          Written Number                       EFT
                                                                                                                                                                                                                                                                                             provider for a given
                                                                                                                          trace number.
                                                                                                                                                                                                                                                                                             payment cycle.


                                                                                                                                                                                                                                                                                                EFT number that
                                                                                                                                                                                                                                                                              Electronic        uniquely identifies a
137.0   2200D                                                                                                                                                                                                C_HDR_WARRANT_TB         C-EFT-TRC-ID      X(15)        5690     Funds Transfer    payment to a
                                                                                                                                                                                                                                                                              Trace Number      provider for a given
                                                                                                                                                                                                                                                                                                payment cycle.

                                                                                       Health Care Claim
138.0   2200D                                                                STC10                           S            Use this element if a second claim status Is needed
                                                                                       Status
                                                                                       Health Care Claim
                                                                                                                          This is the category code. Use code source 507.                                                                                                                                                Crosswalk MMIS status codes to the Health Care
139.0   2200D                                                                STC10-1   Status Category       S AN 1/30
                                                                                                                          Required if STC10 is used.                                                                                                                                                                     Claim Status Category Codes.
                                                                                       Code
                                                                                                                                                                                                                                                                                                                         Crosswalk MMIS status codes and header level
                                                                                       Health Care Claim                  This is the Status code. Use code source 508.
140.0   2200D                                                                SCT10-2                         S AN 1/30                                                                                                                                                                                                   exception codes to the Health Care Claim Status
                                                                                       Status Code                        Required if STC10 is used.
                                                                                                                                                                                                                                                                                                                         Codes.
                                                                                                                          This further modifies the status code in STC10-2.
                                                                                                                          For valid values see Implementation Guide. Examples are:
                                                                                       Entity Identifier                  '13' - Contracted Service Provider
141.0   2200D                                                                STC10-3                         S   ID   2/3
                                                                                       Code                               '17' - Consultant's Office
                                                                                                                          '1E' - HMO
                                                                                                                          '1G' - Oncology Center
                                                                                                                          Required when using NCPDP reject/payment code in STC01-2                                                                                                                                       Will not be generated. The MMIS keeps internal
                                                                                       Code List Qualifier
142.0   2200D                                                                STC10-4                         S   ID   1/3 for status related to a pharmacy claim. If not required by this                                                                                                                                MMIS reject/payment status codes, not NCPDP
                                                                                       Code
                                                                                                                          IG, do not send.                                                                                                                                                                               codes.
                                                                                       Health Care Claim
143.0   2200D                                                                STC11                           S            Use this element is a third claim status is needed
                                                                                       Status
                                                                                       Health Care Claim
                                                                                                                          This is the category code. Use code source 507.                                                                                                                                                Crosswalk MMIS status codes to the Health Care
144.0   2200D                                                                STC11-1   Status Category       S AN 1/30
                                                                                                                          Required if STC11 is used.                                                                                                                                                                     Claim Status Category Codes.
                                                                                       Code
                                                                                                                                                                                                                                                                                                                         Crosswalk MMIS status codes and header level
                                                                                       Health Care Claim                  This is the Status code. Use code source 508.
145.0   2200D                                                                SCT11-2                         S AN 1/30                                                                                                                                                                                                   exception codes to the Health Care Claim Status
                                                                                       Status Code                        Required if STC11 is used.
                                                                                                                                                                                                                                                                                                                         Codes.
                                                                                                                          This further modifies the status code in STC11-2.
                                                                                                                          For valid values see Implementation Guide. Examples are:
                                                                                       Entity Identifier                  '13' - Contracted Service Provider
146.0   2200D                                                                STC11-3                         S   ID   2/3
                                                                                       Code                               '17' - Consultant's Office
                                                                                                                          '1E' - HMO
                                                                                                                          '1G' - Oncology Center
                                                                                                                          Required when using NCPDP reject/payment code in STC01-2                                                                                                                                       Will not be generated. The MMIS keeps internal
                                                                                       Code List Qualifier
147.0   2200D                                                                STC11-4                         S   ID   1/3 for status related to a pharmacy claim. If not required by this                                                                                                                                MMIS reject/payment status codes, not NCPDP
                                                                                       Code
                                                                                                                          IG, do not send.                                                                                                                                                                               codes.




                                                                                                                                                          Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                        Page: 10 of 17                                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                                     New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                   Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                       277 Health Care Claim Status Response




                                                                                              ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                              MMIS SPECIFICATIONS




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                                                              Payer Claim
                                                                                                                                         Required when the claim is located in the Information Source's                                                                                                                                   This segment will not be used because the
148.0   2200D                                      1100 REF   identification       S   1
                                                                                                                                         system.                                                                                                                                                                                          subscriber is always the patient in Medicaid.
                                                              Number
                                                                                                   Reference ID
149.0   2200D                                                                              REF01                          R   ID   2/3 Set to '1K' - Payer's claim number.
                                                                                                   Qualifier
                                                                                                                                                                                                                                                                                                              The TCN
                                                                                                                                                                                                                                                                                                              (transaction control
                                                                                                                                                                                                                                                                                                              number) uniquely
                                                                                                                                                                                                                                                                                                              identifies each claim
                                                                                                                                                                                                                                                                                                              and transaction in
                                                                                                                                                                                                                                                                        S9(17)V
                                                                                                   Payer Claim Control           Reference information as defined for a particular Transaction                                                                                                 Transaction    the claims
150.0   2200D                                                                              REF02                       R AN 1/50                                                                                            C_HDR_TB                 C-TCN-NUM          USAGE        1024
                                                                                                   Number                        set or as specified by REF01.                                                                                                                                 Control Number processing
                                                                                                                                                                                                                                                                        COMP-3
                                                                                                                                                                                                                                                                                                              subsystem and is
                                                                                                                                                                                                                                                                                                              used as the primary
                                                                                                                                                                                                                                                                                                              key for all tables that
                                                                                                                                                                                                                                                                                                              make up a single
                                                                                                                                                                                                                                                                                                              claim.

                                                                                                                                         Required on institutional claims when different than the value
                                                              Institutional Bill
                                                                                                                                         submitted on the 276. If not required by this IG, may be                                                                                                                                         Always populate, it is easier than checking what
151.0   2200D                                      1100 REF   Type                 S   1
                                                                                                                                         provided at the sender's discretion but cannot be required by                                                                                                                                    came on the 276.
                                                              Identification
                                                                                                                                         the receiver.
                                                                                                   Reference ID                          Code qualifying REF02 - Bill Type Identifier
152.0   2200D                                                                              REF01                          R   ID   2/3
                                                                                                   Qualifier                             Set to 'BLT' - Billing Type
                                                                                                                                                                                                                                                                                                               The 3-char type of
                                                                                                                                                                                                                                                                                                               bill code is taken
                                                                                                                                                                                                                                                                                               Type of Bill
                                                                                                                                    Required for institutional claim inquiries.                                                                                                                                from UB92 claim
                                                                                                                                                                                                                                                                                               Code Digits 1-2
                                                                                                                                    Found on UB92 - record 40-4                                                                                      C-TY-OF-BLL-1-2-CD X(02)        1180                      form. It consists of
153.0   2200D                                                                              REF02   Bill Type Identifier   R AN 1/50                                                                                         C_HDR_TB                                                           Type of Bill
                                                                                                                                    Found on 837 CLM-05                                                                                              C-TY-OF-BILL-3-CD X(01)         1179                      facility type class
                                                                                                                                                                                                                                                                                               Code Digit 3
                                                                                                                                    Found on UB92 paper form locator 4                                                                                                                                         (inpatient or
                                                                                                                                                                                                                                                                                                               outpatient) and
                                                                                                                                                                                                                                                                                                               frequency.

                                                                                                                                         Required when the Patient Control Number was submitted on
                                                              Patient Control
154.0   2200D                                      1100 REF                        S   1                                                 the 276 or when available on claims located in the Information
                                                              Number
                                                                                                                                         Source's system. If not required by this IG, do not send.

                                                                                                   Reference ID                          Code qualifying REF02 - Reference Identifier
155.0   2200D                                                                              REF01                          R   ID   2/3
                                                                                                   Qualifier                             Set to 'EJ' - Patient Account Number.
                                                                                                                                                                                                                                                                                                               Any number
                                                                                                                                                                                                                                                                                                               assigned by a
                                                                                                   Patient Control                                                                                                                                   C-HDR-PAT-ACCT-                           Patient Account
156.0   2200D                                                                              REF02                          R AN 1/80                                                                                         C_HDR_TB                                    X(20)        1016                      provider to a
                                                                                                   Number                                                                                                                                            NUM                                       Number
                                                                                                                                                                                                                                                                                                               recipient or claim for
                                                                                                                                                                                                                                                                                                               reference
                                                                                                                                         Required when the Pharmacy Prescription Number was
                                                              Pharmacy
                                                                                                                                         submitted on the 276 or when available on claims located in the
157.0   2200D                                      1100 REF   Prescription         S   1
                                                                                                                                         Information Source's system. If not required by this IG, do not
                                                              Number
                                                                                                                                         send.
                                                                                                   Reference ID                          Code qualifying REF02 - Reference Identifier
158.0   2200D                                                                              REF01                          R   ID   2/3
                                                                                                   Qualifier                             Set to 'XZ' - Pharmacy Prescription Number.
                                                                                                                                                                                                                                                                                                                The prescription
                                                                                                   Pharmacy                                                                                                                                                             S9(9)                                   (RX) number
                                                                                                                                                                                                                                                     C-HDR-DRUG-RX-                            Prescription
159.0   2200D                                                                              REF02   Prescription           R AN 1/50                                                                                         C_HDR_DRUG_TB                               USAGE            990                    assigned by the
                                                                                                                                                                                                                                                     NUM                                       Number
                                                                                                   Number                                                                                                                                                               COMP                                    pharmacy for the
                                                                                                                                                                                                                                                                                                                dispensed drug.
                                                              Voucher                                                                    Required when a voucher is associated with the response
160.0   2200D                                      1100 REF                        S   1                                                                                                                                                                                                                                                  Not used by the MMIS.
                                                              Identifier                                                                 claim. If not required by this IG, do not send.




                                                                                                                                                                         Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                       Page: 11 of 17                                                                                                                                                          November 30, 2009
                                                                                                                                                                                                                                                                                                                                New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                              Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                  277 Health Care Claim Status Response




                                                                                           ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                               MMIS SPECIFICATIONS




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                                                               Claim
                                                               Identification
                                                               Number for
                                                                                                                                      Required when received on the 276 status request. If not
161.0   2200D                                       1100 REF   Clearinghouse    S   1
                                                                                                                                      required by this IG, do not send.
                                                               and Other
                                                               Transmission
                                                               Intermediaries
                                                                                                Reference ID                          Code qualifying REF02 - Reference Identifier
162.0   2200D                                                                           REF01                          R   ID   2/3
                                                                                                Qualifier                             Set to 'D9' - Claim Number.
                                                                                                Clearinghouse                                                                                                                                                                                                                        Populate from 276 request, 2200D loop, REF02 -
163.0   2200D                                                                           REF02                          R AN 1/50
                                                                                                Trace Number                                                                                                                                                                                                                         Clearinghouse Trace number element

                                                                                                                                      Required for institutional or for professional and dental claims
                                                                                                                                      when the service line date is not used. If not required by this
                                                                                                                                      IG, may be provided at the sender's discretion, but cannot be
                                                               Claim Service                                                          required by the receiver. For professional claims, this date is
164.0   2200D                                       1200 DTP                    S   1                                                                                                                                                                                                                       purposes.
                                                               Date                                                                   derived from the service level dates. When reporting a claim
                                                                                                                                      level date, use the date from the Information Source's system
                                                                                                                                      for claim matches, otherwise return the date from the 276
                                                                                                                                      status request.

                                                                                                                                    Use this element for the dates of service submitted on the
165.0   2200D                                                                           DTP01   Date Time Qualifier    R   ID   3/3 original claim.
                                                                                                                                    Set to '472' - Service
                                                                                                                                      This is the qualifier for DTP03. If the date is a single date of
                                                                                                Date Time Period                      service, the begin date equals the end date.
166.0   2200D                                                                           DTP02                          R   ID   2/3
                                                                                                Format Qualifier                      Set to 'RD8' - Range of dates expressed in format CCYYMMDD-
                                                                                                                                      CCYYMMDD

                                                                                                                                                                                                                                                                                                            The date upon which
                                                                                                Claim Service                                                                                                                                                                             First Service     the first service
167.0   2200D                                                                           DTP03                          R AN 1/35                                                                                          C_HDR_TB                 C-HDR-SVC-FST-DT X(10)        1022
                                                                                                Period                                                                                                                                                                                    Date              covered by a claim
                                                                                                                                                                                                                                                                                                            was rendered.


                                                                                                                                                                                                                                                                                                            The date upon which
                                                                                                                                                                                                                                                                                          Last Service      the last service
168.0                                                                                                                                                                                                                     C_HDR_TB                 C-HDR-SVC-LST-DT X(10)        1023
                                                                                                                                                                                                                                                                                          Date              covered by a claim
                                                                                                                                                                                                                                                                                                            was rendered.

        2220D -                                                                                                                                                                                                                                                                                                                      This is situational, whether the Claim Inquiry at the
        Within    Service Line                                                                                                                                                                                                                                                                                                       Line Item level be done for the Line Item priced
169.0                                         >1
        Loop      Information                                                                                                                                                                                                                                                                                                        claims is a decision that will be made by the Client
        2200D                                                                                                                                                                                                                                                                                                                        - MAD.

                                                                                                                                      Required when reporting status information about a service
                                                                                                                                      line.
                                                               Service Line
170.0   2220D                                       1800 SVC                    S   1                                                 For institutional claims, SVC01-2 would be the HCFA HCPCS
                                                               Information
                                                                                                                                      Code and SVC04 would be the Revenue Code if both are used.
                                                                                                                                      If only a revenue code is used, it is reported in SVC01-2.


                                                                                                Composite Medical                     To identify a medical procedure by its standardized codes and
171.0   2220D                                                                           SVC01                          R
                                                                                                Procedure Identifier                  applicable modifiers.




                                                                                                                                                                       Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                     Page: 12 of 17                                                                                                                                                       November 30, 2009
                                                                                                                                                                                                                                                                                                                                      New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                    Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                        277 Health Care Claim Status Response




                                                                                ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                                              MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                                                 N
                                                                                                                          Code identifying the type/source of the entry in SVC-1-2.
                                                                                                                          Values are:
                                                                                                                          'AD' - American Dental Association Codes
                                                                                                                          'HC' - HCPCS Codes. The CPT codes are reported under the
                                                                                       Product or Service                 code HC                                                                                                                                                                                                          MMIS does not carry a procedure type code. This
172.0   2220D                                                                SVC01-1                         R   ID   2/2
                                                                                       ID Qualifier                       'HP' - HIPPS Skilled Nursing Facility Rate Code                                                                                                                                                                  field will need to be derived.
                                                                                                                          'N4' - National Drug Code in 5-4-2 Format
                                                                                                                          'NU' - National Uniform Billing Committee (NUBC) UB92
                                                                                                                          Codes. This is the NUBC Revenue Code.


                                                                                                                                                                                                                                                                                                                                           For Medical Claim
                                                                                                                       If the value in SVC01-1 is 'NU', then this element is an NUBC
                                                                                       Service
173.0   2220D                                                                SVC01-2                         R AN 1/48 Revenue Code. If the revenue code is present here, then                                               C_LI_TB                   R-PROC-CD         X(07)        2042      Procedure Code None
                                                                                       Identification Code                                                                                                                                                                                                                                 HCPCS used at line item level.
                                                                                                                       SVC04 is not used.
                                                                                                                                                                                                                                                                                                                                           Revenue codes used at the header level.

                                                                                                                                                                                                                                                                                                                 This code identifies      For Institutional Claims
                                                                                                                                                                                                                                                                                                                 the level of care the
174.0                                                                                                                                                                                                                        C_LI_TB                   R-REV-CD          X(07)        2112      Revenue Code
                                                                                                                                                                                                                                                                                                                 client is receiving in    HCPCS used at line item level.
                                                                                                                                                                                                                                                                                                                 the nursing home.         Revenue codes used at the header level.

175.0                                                                                                                                                                                                                        C_HDR_DRUG                R-DRUG-CD         x(11)        1813      Drug Code        NDC Code                  For Pharmacy Claims

                                                                                                                                                                                                                                                                                                               The procedure code
                                                                                                                                                                                                                                                                                                               modifier is used to
                                                                                                                      Required when modifiers have been applied to the adjudicated
                                                                                                                                                                                                                                                       C-PROC-MOD-1ST-                          Procedure Code further define and
176.0   2220D                                                                SVC01-3   Procedure Modifier    S AN 2/2 procedure code reported in SVC01-2. If not required by this IG,                                        C_LI_TB                                     X(02)            489
                                                                                                                                                                                                                                                       CD                                       Modifier 1     differentiate the
                                                                                                                      do not send.
                                                                                                                                                                                                                                                                                                               service being billed
                                                                                                                                                                                                                                                                                                               on the claim line.

                                                                                                                      Required when modifiers have been applied to the adjudicated
                                                                                                                                                                                                                                                       C-PROC-MOD-2ND-                          Procedure Code
177.0   2220D                                                                SVC01-4   Procedure Modifier    S AN 2/2 procedure code reported in SVC01-2. If not required by this IG,                                        C_LI_TB                                   X(02)              490
                                                                                                                                                                                                                                                       CD                                       Modifier 2
                                                                                                                      do not send.
                                                                                                                      Required when modifiers have been applied to the adjudicated
                                                                                                                                                                                                                                                       C-PROC-MOD-3RD-                          Procedure Code
178.0   2220D                                                                SVC01-5   Procedure Modifier    S AN 2/2 procedure code reported in SVC01-2. If not required by this IG,                                        C_LI_TB                                   X(02)          5103
                                                                                                                                                                                                                                                       CD                                       Modifier 3
                                                                                                                      do not send.
                                                                                                                      Required when modifiers have been applied to the adjudicated
                                                                                                                                                                                                                                                       C-PROC-MOD-4TH-                          Procedure Code
179.0   2220D                                                                SVC01-6   Procedure Modifier    S AN 2/2 procedure code reported in SVC01-2. If not required by this IG,                                        C_LI_TB                                   X(02)          5286
                                                                                                                                                                                                                                                       CD                                       Modifier 4
                                                                                                                      do not send.
                                                                                                                                                                                                                                                                                                              The billed amount for
                                                                                       Line Item Charge                                                                                                                                                C-LI-SUBM-CHRG-   S9(07)V99              Submitted
180.0   2220D                                                                SVC02                           R   R    1/18 This amount is the original submitted charge                                                      C_LI_TB                                                  1091                    a service on a line
                                                                                       Amount                                                                                                                                                          AMT               COMP-3                 Charge Amount
                                                                                                                                                                                                                                                                                                              item

                                                                                                                                                                                            This is the line item total on the
                                                                                                                                                                                            current claim status. Line item
                                                                                                                                                                                            charges will quite often change
                                                                                                                                                                                                                                                                                                              Final calculated
                                                                                                                           This amount is the amount paid. If the adjudication process is   from the submitted charge
                                                                                       Line Item Payment                                                                                                                                                                 S9(07)V99              Reimbursement reimbursement
181.0   2220D                                                                SVC03                           R   R    1/18 not complete, this is zero-filled.                               based on claims processing         C_LI_TB                 C-LI-REIMB-AMT                 1087
                                                                                       Amount                                                                                                                                                                            COMP-3                 Amount        amount for the line
                                                                                                                                                                                            instructions, ie, global services,
                                                                                                                                                                                                                                                                                                              item.
                                                                                                                                                                                            combining services. Most
                                                                                                                                                                                            payers do not store the 'original
                                                                                                                                                                                            submitted charge'.




                                                                                                                                                           Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                         Page: 13 of 17                                                                                                                                                                         November 30, 2009
                                                                                                                                                                                                                                                                                                                                 New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                               Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                   277 Health Care Claim Status Response




                                                                                   ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                                      MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                                          N
                                                                                                                                                                                   Required on institutional claims
                                                                                                                                                                                   when an NUBC revenue code                                                                                                This code identifies
                                                                                                                          This is the NUBC Revenue Code. When SVC-101 equals 'NU', needs to be reported in addition                                                                                         the level of care the
182.0   2220D                                                                   SVC04     Revenue Code          S AN 1/48                                                                                            C_LI_TB                      R-REV-CD          X(07)        2112      Revenue Code
                                                                                                                          then the NUBC Revenue Code belongs in SVC01-2            to a HCPCS or HIPPS code                                                                                                 client is receiving in    Only apply to UB92 claims.
                                                                                                                                                                                   reported in SVC01-2. If not                                                                                              the nursing home.
                                                                                                                                                                                   required by this IG, do not send.                                                                                                                  HCPCS used at line item level.
                                                                                                                                                                                                                                                                                                                                      Revenue codes used at the header level.
                                                                                                                                                                                                                                                                                                            The number of times
                                                                                                                                                                                                                                                                                                            (days, visits,
                                                                                                                                                                                                                                                                                                            injections, etc) the
                                                                                          Units of Service                                                                                                                                        C-LI-SUBM-UNT-    S9(07)V99              Line Item
183.0   2220D                                                                   SVC07                           R   R   1/15 These are the submitted units of service.                                                    C_LI_TB                                                1092                       service was
                                                                                          Count                                                                                                                                                   NUM               COMP-3                 Submitted Unit
                                                                                                                                                                                                                                                                                                            rendered as
                                                                                                                                                                                                                                                                                                            submitted by the
                                                                                                                                                                                                                                                                                                            provider.
                                                                                                                             Use this segment if the subscriber is the patient.
                                                                                          Service Line Status
184.0   2220D                                      1900 STC            S   >1                                                This segment is used when an information source system has
                                                                                          Information
                                                                                                                             the capability to provide line item information.
                                                                                          Health Claim Care                  Used to convey status of the entire claim or a specific service
185.0   2220D                                                                   STC01                           R
                                                                                          Status                             line.
                                                                                                                                                                                                                                                                                                            A status code
                                                                                                                                                                                                                                                                                                            assigned to each
                                                                                                                                                                                                                                                                                                            exception posted to
                                                                                                                                                                                                                                                                                                            the claim. The
                                                                                          Health Care Claim                                                                                                                                                                                                                      Populate using a crosswalk of Exception status,
                                                                                                                                                                                                                                                                                           Exception        adjudicator looks at
186.0   2220D                                                                   STC01-1   Status Category       R AN 1/30 This is the category code.                                           Use code source 507        C_LI_EXC_TB             C-EXC-STAT-CD     X(01)        4200                                            Exception Code, and Line Item Reimbursement
                                                                                                                                                                                                                                                                                           Status           these exception
                                                                                          Code                                                                                                                                                                                                                                   Status Code.
                                                                                                                                                                                                                                                                                                            codes and assigns a
                                                                                                                                                                                                                                                                                                            claim disposition
                                                                                                                                                                                                                                                                                                            based on their
                                                                                                                                                                                                                                                                                                            values.

                                                                                                                                                                                                                                                                                                         Indicates whether
                                                                                                                                                                                                                                                                                                         the claim
                                                                                                                                                                                                                                                                                                         reimbursement was
                                                                                                                                                                                                                                                                                                         derived from allowed
                                                                                                                                                                                                                                                                                           Line Item
                                                                                                                                                                                                                                                                                                         or billed charge, or if
187.0   2220D                                                                                                                                                                                                             C_LI_TB                 C-REIMB-STAT-CD   X(01)            162   Reimbursement
                                                                                                                                                                                                                                                                                                         the claim was
                                                                                                                                                                                                                                                                                           Status Code
                                                                                                                                                                                                                                                                                                         denied, Medicare
                                                                                                                                                                                                                                                                                                         copay or a
                                                                                                                                                                                                                                                                                                         coinsurance/deducti
                                                                                                                                                                                                                                                                                                         ble.


                                                                                                                                                                                                                                                                                                           Indicates whether
                                                                                                                                                                                                                                                                                                           the claim
                                                                                                                                                                                                                                                                                                           reimbursement was
                                                                                                                                                                                                                                                                                                           derived from allowed
                                                                                                                                                                                                                                                                                           Line Item Claim or billed charge, or if
188.0   2220D                                                                                                                                                                                                             C_LI_EXC_TB             R-CLM-EXC-CD      X(04)        1737
                                                                                                                                                                                                                                                                                           Exception Code the claim was
                                                                                                                                                                                                                                                                                                           denied, Medicare
                                                                                                                                                                                                                                                                                                           copay or a
                                                                                                                                                                                                                                                                                                           coinsurance/deducti
                                                                                                                                                                                                                                                                                                           ble.




                                                                                                                                                             Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                           Page: 14 of 17                                                                                                                                                                November 30, 2009
                                                                                                                                                                                                                                                                                                                                  New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                    277 Health Care Claim Status Response




                                                                                ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                                          MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                                           N
                                                                                                                                                                                                                                                                                                             A status code
                                                                                                                                                                                                                                                                                                             assigned to each
                                                                                                                                                                                                                                                                                                             exception posted to
                                                                                                                                                                                                                                                                                                             the claim. The
                                                                                       Health Care Claim                                                                                                                                                                                    Exception        adjudicator looks at
189.0   2220D                                                                SCT01-2                         R AN 1/30 This is the Status code.                                               Use code source 508.        C_LI_EXC_TB              C-EXC-STAT-CD     X(01)        4200
                                                                                       Status Code                                                                                                                                                                                          Status           these exception
                                                                                                                                                                                                                                                                                                             codes and assigns a
                                                                                                                                                                                                                                                                                                             claim disposition
                                                                                                                                                                                                                                                                                                             based on their
                                                                                                                                                                                                                                                                                                             values.

                                                                                                                                                                                                                                                                                                          Indicates whether
                                                                                                                                                                                                                                                                                                          the claim
                                                                                                                                                                                                                                                                                                          reimbursement was
                                                                                                                                                                                                                                                                                                          derived from allowed
                                                                                                                                                                                                                                                                                            Line Item
                                                                                                                                                                                                                                                                                                          or billed charge, or if
190.0   2220D                                                                                                                                                                                                             C_LI_TB                  C-REIMB-STAT-CD   X(01)            162   Reimbursement
                                                                                                                                                                                                                                                                                                          the claim was
                                                                                                                                                                                                                                                                                            Status Code
                                                                                                                                                                                                                                                                                                          denied, Medicare
                                                                                                                                                                                                                                                                                                          copay or a
                                                                                                                                                                                                                                                                                                          coinsurance/deducti
                                                                                                                                                                                                                                                                                                          ble.


                                                                                                                                                                                                                                                                                                            Indicates whether
                                                                                                                                                                                                                                                                                                            the claim
                                                                                                                                                                                                                                                                                                            reimbursement was
                                                                                                                                                                                                                                                                                                            derived from allowed
                                                                                                                                                                                                                                                                                            Line Item Claim or billed charge, or if
191.0   2220D                                                                                                                                                                                                             C_LI_EXC_TB              R-CLM-EXC-CD      X(04)        1737
                                                                                                                                                                                                                                                                                            Exception Code the claim was
                                                                                                                                                                                                                                                                                                            denied, Medicare
                                                                                                                                                                                                                                                                                                            copay or a
                                                                                                                                                                                                                                                                                                            coinsurance/deducti
                                                                                                                                                                                                                                                                                                            ble.

                                                                                                                          Required when an entity must be identified to further clarify the
                                                                                                                          status code in STC01-2. Required if add'l detail applicable to
                                                                                                                          claim status is needed to clarify the status and the payer's
                                                                                                                                                                                                                                                                                                                                       Don't believe this is necessary, but need to
                                                                                                                          system supports this level of detail.
                                                                                                                                                                                                                                                                                                                                       examine the possible header level exception
                                                                                       Entity Identifier                  See Implementation Guide for valid codes, too numerous to list
192.0   2220D                                                                STC01-3                         S   ID   2/3                                                                                                                                                                                                              codes and how they crosswalk to the Health Care
                                                                                       Code                               here. Examples are:
                                                                                                                                                                                                                                                                                                                                       Claim Status Codes to determine if there are any
                                                                                                                          '13' - Contracted Service Provider
                                                                                                                                                                                                                                                                                                                                       situations where we need to populate this field.
                                                                                                                          '17' - Consultant's Office
                                                                                                                          '1E' - HMO
                                                                                                                          '1G' - Oncology Center
                                                                                                                          Required when using NCPDP reject/payment code in STC01-2                                                                                                                                                     Will not be generated. The MMIS keeps internal
                                                                                       Code List Qualifier
193.0   2220D                                                                STC01-4                         S   ID   1/3 for status related to a pharmacy claim. If not required by this                                                                                                                                              MMIS reject/payment status codes, not NCPDP
                                                                                       Code
                                                                                                                          IG, do not send.                                                                                                                                                                                             codes.

                                                                                                                                                                                                                                                                                                             The date the claim
                                                                                       Status Information                  Format is CCYYMMDD. Use this date for the effective date of                                                                                                      Adjudication     was last processed
194.0   2220D                                                                STC02                           R DT 8/8                                                                                                     C_HDR_TB                 C-HDR-ADJUD-DT    X(10)            963
                                                                                       Effective Date                      status.                                                                                                                                                          Date             by the adjudication
                                                                                                                                                                                                                                                                                                             program.

                                                                                                                                                                                                                                                                                                          The billed amount for
                                                                                       Line Item Charge                                                                                                                                            C-LI-SUBM-CHRG-   S9(07)V99              Submitted
195.0   2220D                                                                STC04                           S   R    1/18 This is the submitted line charge amount.                                                      C_LI_TB                                                 1091                    a service on a line
                                                                                       Amount                                                                                                                                                      AMT               COMP-3                 Charge Amount
                                                                                                                                                                                                                                                                                                          item




                                                                                                                                                           Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                         Page: 15 of 17                                                                                                                                                                    November 30, 2009
                                                                                                                                                                                                                                                                                                                               New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                             Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                 277 Health Care Claim Status Response




                                                                                          ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                               MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                       Final calculated
                                                                                                 Line Item Provider                                                                                                                                                 S9(07)V99            Reimbursement reimbursement
196.0   2220D                                                                          STC05                           S   R    1/18 Use this element for the line item paid amount.                                    C_LI_TB                 C-LI-REIMB-AMT                  1087
                                                                                                 Payment Amount                                                                                                                                                     COMP-3               Amount        amount for the line
                                                                                                                                                                                                                                                                                                       item.
                                                                                                 Health Care Claim
197.0   2220D                                                                          STC10                           S             Use this element if a second claim status Is needed
                                                                                                 Status
                                                                                                 Health Care Claim
                                                                                                                                     This is the category code. Use code source 507.                                                                                                                                                Crosswalk MMIS status codes to the Health Care
198.0   2220D                                                                          STC10-1   Status Category       S AN 1/30
                                                                                                                                     Required if STC10 is used.                                                                                                                                                                     Claim Status Category Codes.
                                                                                                 Code
                                                                                                                                                                                                                                                                                                                                    Crosswalk MMIS status codes and header level
                                                                                                 Health Care Claim                   This is the Status code. Use code source 508.
199.0   2220D                                                                          SCT10-2                         S AN 1/30                                                                                                                                                                                                    exception codes to the Health Care Claim Status
                                                                                                 Status Code                         Required if STC10 is used.
                                                                                                                                                                                                                                                                                                                                    Codes.
                                                                                                                                    This further modifies the status code in STC11-2.
                                                                                                                                    For valid values see Implementation Guide. Examples are:
                                                                                                 Entity Identifier                  '13' - Contracted Service Provider
200.0   2220D                                                                          STC10-3                         S   ID   2/3
                                                                                                 Code                               '17' - Consultant's Office
                                                                                                                                    '1E' - HMO
                                                                                                                                    '1G' - Oncology Center
                                                                                                                                    Required when using NCPDP reject/payment code in STC01-2                                                                                                                                        Will not be generated. The MMIS keeps internal
                                                                                                 Code List Qualifier
201.0   2220D                                                                          STC10-4                         S   ID   1/3 for status related to a pharmacy claim. If not required by this                                                                                                                                 MMIS reject/payment status codes, not NCPDP
                                                                                                 Code
                                                                                                                                    IG, do not send.                                                                                                                                                                                codes.
                                                                                                 Health Care Claim
202.0   2220D                                                                          STC11                           S             Use this element is a third claim status is needed
                                                                                                 Status
                                                                                                 Health Care Claim
                                                                                                                                     This is the category code. Use code source 507.                                                                                                                                                Crosswalk MMIS status codes to the Health Care
203.0   2220D                                                                          STC11-1   Status Category       S AN 1/30
                                                                                                                                     Required if STC11 is used.                                                                                                                                                                     Claim Status Category Codes.
                                                                                                 Code
                                                                                                                                                                                                                                                                                                                                    Crosswalk MMIS status codes and header level
                                                                                                 Health Care Claim                   This is the Status code. Use code source 508.
204.0   2220D                                                                          SCT11-2                         S AN 1/30                                                                                                                                                                                                    exception codes to the Health Care Claim Status
                                                                                                 Status Code                         Required if STC11 is used.
                                                                                                                                                                                                                                                                                                                                    Codes.
                                                                                                                                    This further modifies the status code in STC11-2.
                                                                                                                                    For valid values see Implementation Guide. Examples are:
                                                                                                 Entity Identifier                  '13' - Contracted Service Provider
205.0   2220D                                                                          STC11-3                         S   ID   2/3
                                                                                                 Code                               '17' - Consultant's Office
                                                                                                                                    '1E' - HMO
                                                                                                                                    '1G' - Oncology Center
                                                                                                                                    Required when using NCPDP reject/payment code in STC01-2                                                                                                                                        Will not be generated. The MMIS keeps internal
                                                                                                 Code List Qualifier
206.0   2220D                                                                          STC11-4                         S   ID   1/3 for status related to a pharmacy claim. If not required by this                                                                                                                                 MMIS reject/payment status codes, not NCPDP
                                                                                                 Code
                                                                                                                                    IG, do not send.                                                                                                                                                                                codes.
                                                              Service Line                                                           Required when the service line item identification was
207.0   2220D                                      2000 REF   Item             S   1                                                 submitted on the 276 request and service level status is
                                                              Identification                                                         reported. If not required by this IG, do not send.
                                                                                                 Reference
208.0   2220D                                                                          REF01     Identification        R   ID   2/3 Set to 'FJ' - Line Item Control Number
                                                                                                 Qualifier

                                                                                                                                                                                                                                                                                                           A number that
                                                                                                                                                                                                                                                                                                           identifies an
                                                                                                                                                                                                                                                                                                           individual line item
                                                                                                 Line Item Control                                                                                                                                                  S9(03)
209.0   2220D                                                                          REF02                           R AN 1/50                                                                                        C_LI_TB                 C-LI-NUM                        1073     Line Number       on a claim and used
                                                                                                 Number                                                                                                                                                             COMP
                                                                                                                                                                                                                                                                                                           to identify the line
                                                                                                                                                                                                                                                                                                           items in the related
                                                                                                                                                                                                                                                                                                           history table




                                                                                                                                                                     Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                   Page: 16 of 17                                                                                                                                                      November 30, 2009
                                                                                                                                                                                                                                                                                                                                      New Mexico Medicaid HIPAA 2 Assessment
                                                                                                                                                                                                                                                                                                                                                    Business Rules Comparion
                                                                                                                                                                                                                                                                                                                                        277 Health Care Claim Status Response




                                                                                                 ASC X12N 277 5010 HIPAA SPECIFICATIONS                                                                                                                             MMIS SPECIFICATIONS




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                                                                                                                                                                                                                                                                                                                                                                 N
                                                                                                                                            This is the date of service from the original submitted claim for
                                                                 Service Line
210.0   2220D                                        2100 DTP                      R    1                                                   a specific line item.
                                                                 Date
                                                                                                                                            When the 2220D LOOP is used, this segment must be present.

211.0                                                                                       DTP01      Date Time Qualifier   R   ID   3/3 Set to '472' - Service

                                                                                                                                            Set to 'RD8' - Range of dates expressed in format CCYYMMDD-
                                                                                                       Date Time Period                     CCYYMMDD.
212.0                                                                                       DTP02                            R   ID   2/3
                                                                                                       Format Qualifier                     If the date is a single date of service, the begin date equals the
                                                                                                                                            end date.
                                                                                                                                                                                                                                                                                                Line Item First   Line item First Date
213.0                                                                                       DTP03      Service Line Date     R AN 1/35 Date range in format CCYYMMDD-CCYYMMDD                                                  C_LI_TB                 C-LI-FST-DOS-DT    X(10)        1080
                                                                                                                                                                                                                                                                                                DOS               of Service
                                                                                                                                                                                                                                                                                                Line Item Last    Line item Last Date
214.0                                                                                                                                                                                                                          C_LI_TB                 C-LI-LAST-DOS-DT   X(10)        1083
                                                                                                                                                                                                                                                                                                DOS               of Service
                   Table 2 - Detail,
215.0                                        This was not mapped because Dependent's do not apply to Medicaid, everyone is considered a Subscriber
                   Dependent Level
216.0
                                                                                                                                            To indicate the end of the transaction set and provide the count
                                                                                                       Transaction Set
217.0   Trailer                                1     2700 SE                       R    1                                    R              of the transmitted segments (including the ST and SE                                                                                                                                           This will be created by translator.
                                                                                                       Trailer
                                                                                                                                            segments).




                                                                                                                                                                            Appendix A.5 - 277 - Clairms Status Reponse
        Worksheet: 277 - Outbound                                                                                                                                                          Page: 17 of 17                                                                                                                                                         November 30, 2009

								
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