Claim Status API JSON-to-EDI Contents

Use our OpenAPI Spec JSON file as a reference for development. Notes on the data in the following sections include:

The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: for example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
If a field is required, the Constraints entry notes it.

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

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

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

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

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To obtain a license that also provides access to the full requirements for these transactions, visit https://x12.org/licensing. We make every effort to ensure consistency between our APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.

See JSON-to-EDI API Mapping.

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

Claim Status 276 Request

Identification Leader (Request)

Providers (Request)

Subscriber (Request)

Dependent (Request)

Encounter (Request)

Claim Status 277 Response

Header (Response)

Payer (Response)

Providers (Response) 2100B/C

Subscriber (Response) 2100D

Dependent (Response) 2100E

Claims (Response) 2200D

Claim Status (Response) 2200D/E

Service Details (Response) 2220D/E

Error Response

Claim Status 277 Request

Identification Leader (Request)

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

Providers (Request) 2100B/C

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

Subscriber (Request) 2100B/C

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

Dependent (Request)

Name	Element	Loop	Description	Constraints
`dependent` (Object)			Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.	S
`firstName`	NM104	2100E	Dependent’s first name. Maps to dependent `firstName`.	1/35 R
`lastName`	NM103	2100E	Dependent’s last name. Maps to dependent `lastName`.	1/60 R
`gender`	DM03	2000E	Dependent’s gender code. Options: F or M. Required if available.	1/1 S
`dateOfBirth`	DM02	2000E	Dependent’s birth date. Maps to dependent `birthDate`.	1/35 S
`groupNumber`	REF01	2200E	The group number associated with the dependent. Maps to dependent `groupNumber`.	1/50 S

Encounter (Request)

Name	Elements	Description	Constraints
`encounter` (Object)		The claim/encounter information, for example a doctor visit. Generic for: 2200D - Subscriber 2200E - Dependent	S
`beginningDateOfService`	DTP03	Date Time Period: Start Date maps to `claimServiceDateStart`.	1/35 R
`endDateOfService`	DTP03	Date Time Period: End Date maps to `claimServiceDateEnd`.	1/35 R
`trackingNumber`	TRN02	The claim status tracking number assigned to the status query for the claim.	1/50 R
`submittedAmount`	AMT02	Submitted total charges. Value goes in AMT02 where AMT01=T3 R	1/18 R
REF02 Values		Check the requirements for REF02 values and apply if known.	S
`tradingPartnerClaimNumber`	REF02	The payer assigned claim number. Values go in REF02 where REF01=1K. Required when a claim is in the Information Source's system.	1/50 S
`locationIdentifier`	REF02	R if application or location system identifier is known. Value goes in REF02 where REF01=LU	1/50 S
`billingType`	REF02	Billing type reference ID. Example: billing type for inpatient services is 111. Value goes in REF02 where REF01=BLT. Required for institutional claims if search refinements are necessary.	1/50 S
`patientAccountNumber`	REF02	Patient account number provided by service provider. Value goes in REF02 where REF01=EJ	1/50 S
`pharmacyPrescriptionNumber`	REF02	Patient pharmacy prescription number. Value goes in REF02 where REF01=XZ Required if a pharmacy claim search needs additional search criteria.	1/50 S
`clearingHouseClaimNumber`	REF02	Required when there is a Claim number provided by clearing house. Value goes in REF02 where REF01=D9	1/50 S

Claim Status 277 Response

Identification Leader (Response)

Name	Description
`controlNumber`	Provided by the submitter in the 270 Request. Transaction Set Control Number.
`tradingPartnerServiceId`	ID used by clearinghouse for the trading partner.

Payer (Response)

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

Name	Element	Loop	Description	Constraints
`payer` (Object)			The person holding the insurance policy.	S
`organizationName`	NM103	2100A	Organization Name, required.	2/80 R
`payerIdentification`	NM109	2100A	Payer identification (in the [Response 200 pop-up] (ref:claimstatus), the X12 segment in the `payerIdentification` is the same as that of the `trandingPartnerServiceId`.)	2/80 R
`centersForMedicareAndMedicaidServicePlanId`	NM109	2100A	Centers For Medicare and Medicaid Service Plan Id. If NM108 = XV, this field must be used to push the CMS ID into NM109 as Payer ID for this loop.	2/80 S
`contactInformation`(Object)				S
`name`	PER02	2000A	Name of the person to contact	1/35 S
`electronicDataInterChangeAccessNumber`	PER[04,06,08]	2000A	Electronic Data Interchange Access Number	1/256 S
`email`	PER[04,06,08]	2000A	email	1/256 S
`Fax`	PER[04,06,08]	2000A	fax	1/256 S
`phone`	PER[04,06,08]	2000A	phone	1/256 S
`phoneExtension`	PER[04,06,08]	2000Av	Phone Extension	1/256 S

Providers (Response) 2100B/C

Name	Elements	Description	Constraint
`providers` (Array of objects)		Generic for: Billing (Information Receiver Loop 2100B) Service Providers (Loop 2100C)	R
`organizationName`	NM103	Provider’s organization name. Can use organization or last name.	1/60 S
`firstName`	NM104	Provider first name. Maps to `providerName`	1/35 S
`lastName`	NM103	Provider last name. Can use organization or last name. Maps to provider `lastname`.	1/60 S
One of the following NM109 IDs is required.
`npi`	NM109	National Provider Identification Code Qualifier. Maps to provider `npi`. NM108=XX	2/80 R
`taxId`	NM109	Electronic Transmitter Identification Number (ETIN). Established by Trading Partner agreement. NM108=FI	2/80 R
`providerType`	NM101	Billing, Attending, Operating, Other Operating, Rendering Code for entity (Billing or Service) Billing Provider: Loop 2100B, NM101=41 (required) Service Provider: Loop 2100C, NM101=1P if this is not present it is added; npi = BillingProvider taxId ID	2/3 R

Subscriber (Response) 2100D

Name	Element	Description	Constraints
`subscriber` (Object)			R
`memberId`	NM109	Member ID for the subscriber. Maps to `subscriberId`.	2/80 R
`firstName`	NM104	Subscriber’s first name. Maps to subscriber `firstName`	1/35 S
`lastName`	NM103	Subscriber’s last name. Maps to subscriber `lastName`.	1/60 S

Dependent (Response) 2100E

Name	Element	Description	Constraints
`dependent` (Object)			S
`firstName`	NM104	Dependent’s first name. Maps to dependent `firstName`.	1/35 S
`lastName`	NM103	Dependent’s last name. Maps to dependent `lastName`.	1/60 S

Claims (Response) 2200D

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

Name	Element	Description	Constraints
`claimStatus` (Object)		Generic for: 2200D - Subscriber 2200E - Dependent	S
`statusCategoryCode`	STC01-1	Healthcare claim status category code. Code from a specific industry code list. Example: F3	1/30 R
`statusCategoryCodeValue`		Value of the Status category code. Example: F3=Finalized/Revised - Changes to Adjudication information	1/30 R
`statusCode`	STC01-02	Status of the claim or a service line. Example: 3	1/30R
`statusCodeValue`		Text describing the status code. Example: 3=Claim has been adjudicated and is awaiting payment cycle.	1/100 R
`entityCode`	ST01-03	Code identifying an organizational entity, location, property or an individual. Example: 2P	2/3 S
`entity`	ST01-03	Text describing the entity code. Example: 2P value is Public Health Service Facility	1/100 S
`effectiveDate`	STC02	Date the claim was placed in this status by the information source’s adjudication process. Format: YYYYMMDD	8/8 R
`submittedAmount`	STC04	Total claim charge amount. This value may differ from the submitted total claim charge due to claim splitting and other claims processing instructions.	1/18 S
`amountPaid`	STC05	Claim payment amount.	1/18 S
`paidDate`	STC06	Date of the denial or approval of the claim. Format: YYYYMMDD	8/8 S
`checkIssueDate`	STC08	Check issue or EFT funds available date. Format: YYYYMMDD	8/8 S
`checkNumber`	STC09	Check or EFT trace number.	1/16 S
`trackingNumber`	TRN02	Referenced transaction trace number. Provides unique ID for the transaction.	1/50 R
`claimServiceDate`	DTP03	Claim service period. Date or Date range, format YYYYMMDD	1/35 R
One REF02 value is required, based on the REF01 code.
`tradingPartnerClaimNumber`	REF02	The payer’s assigned control number. REF01 = 1K	1/50
`patientAccountNumber`	REF02	The Patient Account Number. REF01 = EJ	1/50
`clearingHouseClaimNumber`	REF02	The clearing house Claim Number. REF01 = D9	1/50

Service Details (Response) 2220D/E

Name	Element	Description	Constraints
`serviceDetails` (Array of Objects)		Generic for: 2200D - Subscriber 2200E - Dependent	S
`service` (Object)		Required when status is requested for Service Lines.	S
`serviceIdQualifierCode`	SVC01-1	Code identifying the type/source of the descriptive number in Product/Service ID. Code Example: AD See the X12 EDI 277 implementation guide for more details.	2/2 R
`serviceIdQualifier`		String associated with the service code. Example: American Dental Association Codes	1/100 R
`procedureId`	SVC01-2	Identifying number for a product or service.	1/48 R
`submittedAmount`	SVC02	Amount submitted for the service. This is the line item total on the current claim service status.	1/18 R
`amountPaid`	SVC03	Amount paid for the service.	1/18
`revenueCode`	SVC04	National uniform billing committee revenue code.	1/48 S
`submittedUnits`	SVC07	Original submitted units of service.	1/15 R
`status` (Array)
`statusCategoryCode`	STC01-1	The health care claim status category code. Example: F3	1/30 R
`statusCategoryCodeValue`		Explanatory value of the category code. F3 = Finalized/Revised - Adjudication information has been changed	R
`statusCode`	STC01-2	Status code used to identify the status of an entire claim or a service line. Example: 3	1/30 R
`statusCodeValue`		Status Code explanatory value. 3 = Claim has been adjudicated and is awaiting payment cycle.	1/100 R
`entityCode`	STC01-3	Code for the entity. Example: 2P See the X12 EDI 277 implementation guide for more details.	2/3 S
`entity`		Explanatory value of the entity code. Example: 2P = Public Health Service Facility	1/100 S
`effectiveDate`	STC02	Effective date of the status information. The date the service was placed in this status by the information source’s adjudication. Date or Date range, format YYYYMMDD	8/8 R

Error Response

Name	Description
`errorResponse` (Object)
`code`	Code for the error. Example: INVALIDMISSINGINPUTDATA
`description`	Description of the error code. Value provided in Payer ID should be a valid Optum assigned ERA Payer ID.
`errors` (Array of objects)
`field`	Attribute that is bad.
`value`	Value of that attribute.
`code`	Code for the error. Example: INVALIDVALUE
`location`	Segment/location where error occurred. If this is a network/system error, there is no location attribute. Example: $.payerBenefits[0].payer
`followupAction`	Follow-up action required for the error. For AAA errors, this is the value for AAA04

Related Topic

JSON-to-EDI API Mapping

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Contents

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