Chapter 1. Purpose and Business Information

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1.1 Implementation Purpose and Scope

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For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

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The purpose of this implementation guide is to provide standardized data requirements and content for all users of the ASC X12 Health Care Claim Status Request (276) and the ASC X12 Health Care Information Status Notification (277). This implementation guide focuses on the use of the 276 to request the status of a health care claim(s) and the 277 to respond with the information regarding the specified claim(s). This implementation guide provides detailed explanations of the transaction sets by defining uniform data content, identifying valid code tables, and specifying values applicable for the business focus of the 276 Health Care Claim Status Request and the 277 Health Care Claim Status Response. The intention of the developers of the 276 and 277 is represented in the guide.

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Entities using the 276 to request health care claim status include, but are not limited to, hospitals, nursing homes, laboratories, physicians, dentists, allied professional groups, employers, and supplemental (i.e., other than primary payer) health care claims adjudication processors.

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Organizations sending the 277 response include payers, who may be insurance companies; third party administrators; service corporations; state and federal agencies and their contractors; and any other entity that processes health care claims.

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Other business partners affiliated with the 276 and/or the 277 include billing services; consulting services; vendors of systems; software and EDI translators; and EDI network intermediaries such as Automated Clearing Houses (ACHs), Value-Added Networks (VANs), and telecommunications services.

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