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Back  RFI # 2087: Unsolicited 'Finalized' 277s

Formal vs. Informal Help Informal Formal

Submitter

Dennis Zanetti

Description

Hello - Is there a compliant way for a health plan to send a 277 containing Finalized (F Claims Status Category codes) an unsolicited mode (i.e. not in response to a 276)? We would like to receive these responses as a notification that a plan has completed processing of a claim, and not to have to rely on an 835.

The 277CA only supports pre-processing codes and the U277 only supports Pending codes. Why can't they support all codes?

Submitter Assigned Keywords

277 unsolicited

Response

None of the published 277 Implementation Guides support sending an unsolicited notification of finalized claims. That is one of the business functions of the 835 transaction.

Each of the published 277 transactions is designed to perform a specific business function and to ensure consistency with each one's intended business use; the allowable Claim Status Category Codes are limited per guide or business function. The 277CA supports the function of pre-processing claim editing and acknowledgement and uses the Acknowledgement or 'A' Category Codes. The 277 Pending supports the function of listing all claims still processing (not finalized) in the system and uses the Pending 'P' Category Codes. The 277 Request for Additional Information supports the function of requesting additional information from the provider to support a health care claim and uses the Request or 'R' Category Codes. The 276/277 is a paired transaction that supports the request for claim status (276) and the 277 is the response indicating status on the claim(s) requested. The 276/277 allows for the use of all Category Codes, except the 'R' codes, because payers capabilities for providing status on pre-processed claim data vs. claims accepted for adjudication processing varies.

Recommendation

If you wish this functionality to be considered for a future 277 guide version, a change request would need to be filed and include a detailed business case for why this function is needed and the business problem it solves. More information on change requests can be found at http://changerequest.x12.org.

To date, no entity has brought forth the business case or documented need for an unsolicited notification of finalized claims. We assume this is due to the fact that the 835 already meets that notification function, as well as providing the adjudication results needed to perform automated patient account posting. Creating and sending an unsolicited 277 list of finalized claims (which would not have adjudication results) prior to or in addition to the 835 would seem to add additional administrative steps/burdens to payers and providers, as well as duplicate a basic function of the 835 transaction, which is already mandated for use.
Submission 8/28/2015
Status Date 10/9/2015
Status F - Final
Primary References
Document 005010X212
SectionTable 2
Page80
Table2
Loop2200D
Segment PositionSTC
Element Position01
Component Position1
External Code ListClaim Status Category Codes