C.4 ISA01 Authorization Information Qualifier ‘00’ ‘00’ (zero zero) – No Authorization Information Present (no meaningful information in ISA02) C.4 ISA02 Authorization Information Blank (fill with 10 spaces) C.4 ISA03 Security Information Qualifier ‘00’ ‘00’ – No Authorization Information Present (no meaningful information in ISA04) C.4 ISA04 Security Information Blank (fill with 10 spaces) C.4 ISA05 Interchange ID Qualifier ‘ZZ’ ZZ (Mutually Defined) C.4 ISA06 Interchange Sender ID Electronic Transmitter Identification Number (ETIN) C.5 ISA07 Interchange ID Qualifier ‘ZZ’ ZZ (Mutually Defined) C.5 ISA08 Interchange Receiver ID PHC100680301406 PHC100680301406 C.5 ISA09 Interchange Date Interchange Creation Date in YYMMDD format C.5 ISA10 Interchange Time Interchange Creation Time in HHMM format C.5 ISA11 Interchange Repetition Separator > PHC will utilize the symbol: (colon) as the repetition separator. C.5 ISA12 Interchange Control Version Number ‘00501’ Indicates version number C.5 ISA13 Interchange Control Number A control number assigned by the interchange sender C.6 ISA14 Acknowledgement Requested ‘0’,‘1’ 0 No Interchange Acknowledgment Requested 1 - Interchange Acknowledgment Requested C.6 ISA15 Usage Indicator ‘P’ P - Production data C.6 ISA16 Component Element Separator ‘!’ A ! must be sent in this field. C.10 IEA Interchange Control Trailer C.10 IEA01 Number of Included Functional Groups Count of the number of functional groups included in an interchange. C.10 IEA02 Interchange Control Number Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13. Outbound values:
TR3 Page # Reference Name Codes Expected Value C.3 ISA Interchange Control Header All positions within each of the data elements must be filled. C.4 ISA01 Authorization Information Qualifier ‘00’ ‘00’ (zero zero) – No Authorization Information Present (no meaningful information in ISA02) C.4 ISA02 Authorization Information Blank (fill with 10 spaces) C.4 ISA03 Security Information Qualifier ‘00’ ‘00’ – No Authorization Information Present (no meaningful information in ISA04) C.4 ISA04 Security Information Blank (fill with 10 spaces) C.4 ISA05 Interchange ID Qualifier ‘ZZ’ ZZ (Mutually Defined) C.4 ISA06 Interchange Sender ID PHC100680301406 ‘PHC100680301406’ This field must be filled with 15 spaces and be left justified. C.5 ISA07 Interchange ID Qualifier ‘ZZ’ ZZ (Mutually Defined) C.5 ISA08 Interchange Receiver ID Value submitted in ISA06 of the 276 Request C.5 ISA09 Interchange Date Interchange Creation Date in YYMMDD format C.5 ISA10 Interchange Time Interchange Creation Time in HHMM format C.5 ISA11 Interchange Repetition Separator ‘>’ PHC will utilize the ‘>’ as the repetition separator. C.5 ISA12 Interchange Control Version Number ‘00501‘ Indicates version number C.5 ISA13 Interchange Control Number A control number assigned by the interchange sender C.6 ISA14 Acknowledgement Requested ‘0’ 0 – No Acknowledgment Requested C.6 ISA15 Usage Indicator ‘P’ P - Production data C.6 ISA16 Component Element Separator ‘!’ A ‘!’ must be sent in this field. C.10 IEA Interchange Control Trailer C.10 IEA01 Number of Included Functional Groups Count of the number of functional groups included in an interchange. C.10 IEA02 Interchange Control Number Control number assigned by the interchange sender that should be nine characters and be identical to the value in ISA13.
If submitters have made a request of PHC for a claim that should be handled by one of our vendors, submitters will receive a 277 Response indicating that the data could not be found. See the Claim Status Category Code Table, code source 507 or 508, for more information about response codes used in the 277 Transaction. CLAIM STATUS CATEGORY AND STATUS CODE Response uses the Claim Status Category Codes and Status Codes to identify security validation requirement issues and to indicate PHC business edits. The following table lists all codes supported by PHC within the 277 Transaction, Loop 2200D, Elements STC01-1 and STC01-2. The first column lists the codes used for the STC01-1 element and the corresponding STC01-2 value appears in the second column. Claim Status Category Code STC01 Claim Status Code STC02 Claim Status Category Code Descriptions Claim Status Code Descriptions F1 65 Finalized/Payment-The claim/line has been paid. Claim/line has been paid. F3 519 Finalized/Revised - Adjudication information has been changed Adjustment Amount P1 20 Pending/In Process-The claim or encounter is in the adjudication system. Accepted for processing. P2 710 Pending/Payer Review-The claim/encounter is suspended and is pending review (e.g. medical review, re-pricing, Third Party Administrator processing). Line Adjudication Information. Note: At least one other status code is required to identify the data element in error. F2 585 Finalized/Denial-The claim/line has been denied. Denied Charge or Non-covered Charge F4 696 Finalized/Adjudication Complete - No payment forthcoming-The claim/encounter has been adjudicated and no further payment is forthcoming. Claim Adjustment Group Code. P5 55 Pending/Payer Administrative/System hold Claim assigned to an approver/analyst. ACKNOWLEDGEMENTS AND/OR REPORTS For each 276 Claim Status Request submitted to PHC, one of the following will be returned: TA1 Interchange Acknowledgement if the ISA/IEA envelope cannot be processed. 999 Implementation Acknowledgement if the 276 transaction contains HIPAA compliancy errors within the ST/SE segments. 277 Claim Status Response containing the requested claim inquiry. TRADING PARTNER AGREEMENTS A completed EDI Enrollment form is required for all providers, clearinghouses and software vendors wishing to connect directly with PHC to exchange Claim Status Request and Response (276/277) transactions.
50 2100C NM102 Entity Type Qualifier 1,2 1= Person 2= Nonperson entity 50 2100C NM103 Name Last or Organization Name Provider Last or Name 50 2100C NM104 Name First Provider First Name Required when the value in NM102 = “1" 51 2100C NM108 Identification Code Qualifier XX XX = NPI 51 2100C NM109 Identification Code Provider Identifier Enter NPI 54 2000D DMG Subscriber Demographic Information 54 2000D DMG01 Date Time Period Format Qualifier D8 D8 = Date expressed in format CCYYMMDD 55 2000D DMG02 Date Time Period Date of Birth 55 2000D DMG03 Gender Code F,M F = Female M = Male 56 2100D NM1 Subscriber Name 56 2100D NM101 Entity Identifier Code IL IL = Insured or Subscriber TR3 Page # Loop ID Reference Name Codes Length Expected Value 56 2100D NM102 Entity Type Qualifier 1 1 = Person 57 2100D NM103 Name Last or Organization Name Subscriber’s last name 57 2100D NM104 Name First Subscriber’s first name 57 2100D NM108 Identification Code Qualifier MI MI 57 2100D NM109 Identification Code Subscriber Identifier 58 2200D TRN Claim Status Tracking Number 58 2200D TRN01 Trace Type Code 1 1 = Current Transaction Trace Numbers 58 2200D TRN02 Reference Identification Claims status tracking number