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Back  RFI # 575: 276/277 vs. DDE Information

Formal vs. Informal Help Informal Formal

Submitter

Suzanne Stewart

Description

We're having a problem because we're getting some very limited information on the 277 vs. what is on a health plans website. It is our understanding that the health plan can provide additional detail information about the status of a claim or service over and above what is contained in STC01 through STC09 by utilizing STC10 and 11. For instance, additional messages like a status 98 (Charges applied to deductible) or 12 (One or more originally submitted procedure codes have been combined.) could be sent in STC10 and 11 after a status 104 (Processed according to plan provisions) is sent in STC01 with a Status Category code of F0 (Finalized-The claim/encounter has completed the adjudication cycle and no more action will be taken.). The health plan says that their 277s are compliant without using STC10 or 11. Is our understanding correct?

Submitter Assigned Keywords

276 277 Claim Status Code DDE

Response

The submitter is correct that the inclusion of the STC10 and STC11 data elements can provide a more complete message from the payer to the provider. The notes for both of these data elements, “Use this element if a second (or third) claim status is needed.” and the front matter of the 4010X93A1 which states in section 2.2.3.8 “The composite Health Care Claim Status can be used one time (STC01 only) or in conjunction with the other iterations (STC10 and/or STC11) to convey complete status information.” reinforce the value of these data elements. In addition to the STC10 & STC11 situational note usage, these elements are required when there is guidance included with the STC01 Claim Status Code. The Code Maintenance Committee approved a change to Status Code ‘21’ that will require the use of an additional status code. The change is “This change effective 1/1/2008: Missing or invalid information. Note: At least one other status code is required to identify the missing or invalid information.”

Recommendation

This response does not address any HIPAA policy issues related to the 277 vs. DDE data content. You may submit questions of HIPAA policy to CMS at askhipaa@cms.hhs.gov
Submission 6/29/2007
Status Date 8/24/2007
Status F - Final
Primary References
Document 004010X093
SectionDetail
Page164
Set ID277
Loop2200D
Segment IDSTC
Element Position10
External Code ListHealth Care Claim Status Code