HIPAA: 276/277 Claim Status Request/Response Transactions FAQs
Q: Why doesn't Medi-Cal require encryption for files that are transferred in the 276/277 transactions?
A:
The 276/277 transactions reside in the
Transaction
Services area of the Medi-Cal Web site. All pages in this area of the Web site are encrypted using a technology known as
Secure Sockets Layer (SSL). Files uploaded and downloaded through these pages are also encrypted through SSL.
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Q: Will we be able to check the status of paper claims and appeals that are currently being processed?
A:
Yes. You will be able to check the status of paper claims and appeals using the new 276 transaction. Note, however, that it may take
up to three weeks from the time you submit an appeal before it shows up in the Medi-Cal system. The delay for a paper claim is a few
days (usually less than five). During this time, the response will indicate that the claim or appeal could not be found.
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Q: What is the “TA1”?
A:
The “TA1” is the Interchange Acknowledgement. It can be used to acknowledge receipt of a file as well as to indicate
errors in the Interchange (or ISA/IEA file “wrapper”). For Medi-Cal, the TA1 is only returned when errors exist at the
Interchange level.
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Q: Currently, the 277 response returns 12 weeks' worth of claims history. But didn't the Webcast presentation state it would
return up to three years' worth of claims history?
A:
Three-years' worth of history was discussed, but only 12 weeks' worth of history will be available for the initial implementation.
This is the amount of history that is readily available in the Medi-Cal system. A three-year history may be available in the future.
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Q: Does the 276 Inquiry transaction only involve uploading claims files via the Medi-Cal Web site, or does it also involve
downloading claims status for claims submitted via CMC?
A:
Claim status inquiries can be done for paper claims as well as Computer Media Claims (CMC). You must upload 276 claim status inquiry
files to be able to download 277 claim status response files. Unsolicited 277 claim status response files are
not automatically
generated for CMC claims.
Medi-Cal also provides a real-time claim status inquiry method through the Provider Telecommunications Network (PTN) and the
Medi-Cal Web Site. The PTN is a voice response system and requires a provider ID and Provider Identification Number (PIN) to access
(refer to the Provider Telecommunications Network (PTN) section of the provider manual for more information about PTN).
In addition, submitters can perform real-time DDE claim status inquiry transactions through the Transaction Services area of the
Medi-Cal Web site. To access this inquiry transaction, log on to Transaction Services (a user ID and password are required) and click the "Automated Provider Services"
link.
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Q: Should we proceed with sending 276 Inquiry transactions even though we will not be receiving the 277 Response transaction?
A:
A 277 Response transaction will be generated for every 276 Inquiry transaction, regardless of whether the claim was found in the
Medi-Cal claims processing system.
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Q: Is it possible to receive a hard copy response to a 276 Inquiry transaction?
A: No. 277 Response transactions are only available through the Medi-Cal Web site.
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Q: Is there a way for me to completely automate the upload process?
A:
It may be possible to automate the process, but Medi-Cal does not recommend doing so. If you do attempt to automate the process, you
are strongly advised to take security into account in all aspects of the process.
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Q: Will the real-time inquiry transaction be eliminated once the 276 Batch Inquiry transaction is fully functional?
A:
There are no plans to discontinue the real-time (DDE) Internet claim inquiry transaction or the claim inquiry transaction available
through the Provider Telecommunications Network (PTN).
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Q: How does the 99-line limitation work for outpatient claims that are procedure- or NRC-driven? Is it one line per procedure/NRC
or one line per date span?
A:
The answer depends on whether you are doing service-level or claim-level inquiries. As indicated in the
277
Health Care Claim Status Response Companion Guide, Medi-Cal will process claim status inquiry transactions using the following
criteria:
Search Criteria 1 (CCN):
a. Provider Identifier (Loop 2100C, NM109)
b. Subscriber Identifier (Loop 2100D, NM109)
c. Payer Claim Control Number (Loop 2200D, REF02)
Search Criteria 2 (Service Level):
a. Provider Identifier (Loop 2100C, NM109)
b. Subscriber Identifier (Loop 2100D, NM109)
c. Service Line Date (Loop 2210D, DTP03)
d. Service Identification Code (Loop 2210D, SVC01-2)
Search Criteria 3 (Claim Level):
a. Provider Identifier (Loop 2100C, NM109)
b. Subscriber Identifier (Loop 2100D, NM109)
c. Claim Service Period (Loop 2200D, DTP03)
d. Total Claim Charge Amount (Loop 2200D, AMT02)
Medi-Cal processes and pays claims at the line level for drug (pharmacy or medical supply), long term care (LTC), outpatient,
medical and vision care claims so that the total claim charge is the billed amount for the claim line. For inpatient, crossover
and compound drug claims, the total claim charge is the billed amount for the entire claim, since these claim types are paid at a
claim level.
The 99-line limit applies to a single claim status inquiry transaction, not to the entire file of claim status inquiry
transactions. Medi-Cal will return up to 99 claim status responses for each claim status inquiry (at the claim- or service-line
level). For claim-level inquiries, this means up to 99 claims for the same provider and recipient, within the date range, with the
same billed amount. For service-level inquiries, this means up to 99 claim lines with the same provider and recipient, within the
date range, with the same procedure code. (It is unlikely that a recipient would have 99 of the same procedures [service
identification codes] on the same day.)
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Q: How long does it typically take for a paper claim to show up in the DDE and PTN systems for a claim status inquiry?
A:
It takes a few days (usually less than five) from the time you submit a paper claim before it shows up in the DDE and PTN systems. If
the 277 Response indicates a "pending" status, this may mean that the claim contains an error (which may lead to claim denial), or it
may simply mean that processing of the claim has been temporarily paused so that the claim can be reviewed by an examiner. Note that
the response time for the DDE and PTN claim status responses is only a few seconds.
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Q: How long does it take for batch claim status inquiries to be returned?
A:
Batch claim status inquiries are returned the next business day if they are received before the 6 p.m. PST cutoff Monday through
Friday. For example, if a claim status inquiry is received on Friday at 4 p.m. PST, the 277 Response will be available on Monday
morning. If a claim is received on Friday at 7 p.m. PST, the 277 Response will be available on Tuesday morning.
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Q: I volunteered to be a beta tester and was told that testers would be selected by September 14, 2004. I have not heard anything.
Will we be contacted at a later date?
A: Beta testers will be contacted in December 2004, at the earliest.
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Q: After submitting a paper claim, how long should we wait before inquiring about it?
A:
It is recommended that you wait at least two weeks before inquiring. If you inquire before two weeks have elapsed, the system may
simply indicate that the claim is in a "pending" status. However, an inquiry will confirm that the claim was received.
Note that there will be an additional one-week delay in obtaining payment and checkwrite information for paid claims due to the
pre-checkwrite review of claims. A claim is not released for payment until a minimum of two weekends after receipt of the claim.
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Q:
When we submitted our Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153), we indicated
that we would submit only ANSI X12 837 claim types electronically. Do we have to submit additional agreement forms indicating that we
also want to submit ANSI X12 276/277 claim types?
A:
No. If you are already billing electronically for providers, you do not need to resubmit agreement forms indicating that you will be
submitting the ANSI X12 276/277 claim types. For submitters, the only requirement is that you have an established relationship with
the provider(s) for which you are submitting the 276/277 transaction.
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Q: When we select a file to upload, why do we then have to enter the Claim Control Number (CCN), service-level search or
claim-level search if we are given the VOLSER number?
A:
The VOLSER number is a tracking number assigned to the file that you send as part of the 276 Inquiry transaction. When the 277
Response file and/or error reports are created, they will have the same VOLSER number. The CCN, service-level and claim-level search
pertain to the 276 Inquiry file data, which are specific components of the transaction.
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Q: Are the 276/277 Claim Status Batch Inquiry/Response transactions available now?
A:
They are not available at this time. They are expected to be available in the second or third quarter of 2005. Medi-Cal will continue
to communicate the implementation status and date of the 276/277 Claim Status Batch Inquiry/Response transactions via the Medi-Cal
Updates and Medi-Cal Web site.
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Q: Is the Claim Control Number (CCN) the number on the Remittance Advice Details (RAD)? Are we supposed to obtain the CCN
from the Internet before checking a claim's status?
A:
Yes, the CCN appears on your RAD and is the number assigned to the claim by Medi-Cal. You do not need to obtain the CCN from the
Internet before checking a claim's status. (You could obtain the CCN by doing a real-time DDE inquiry on the Internet, but by then you
would already have the claim status response, so there would be no need to do a batch 276 inquiry.)
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Q: What is the difference between the TA1 Acknowledgment and the Claim Status Error report?
A:
The TA1 Acknowledgement is an X12 file that is returned when there is an interchange error. No processing takes place when interchange
errors exist (the 276 Inquiry transaction inside the interchange is not even read). The Claim Status Error report describes errors
encountered in the 276 Inquiry transaction itself. It is a user-friendly version of the 997 Functional Acknowledgement.
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Q: Is the service identification code a required field?
A:
The service identification code is a required field for service-level inquiries. If the 2210D Service Loop is included in the 276
Inquiry transaction, the service identification code is also required.
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Q: Does the Provider Identification Number (PIN) serve as the password when logging on to Transaction Services?
A:
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Q: What is beta testing?
A:
Beta testing is testing performed by users outside the development team. Medi-Cal has invited a cross section of claim submitters,
vendors and providers to submit 276 transactions to test the system. This helps resolve problems before the system is made available
to all submitters and helps ensure that all systems are properly configured.
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Q: Will Medi-Cal schedule seminars for the 276/277 transactions?
A:
There are no plans for face-to-face seminars but an archived
Webcast seminar for the 276/277 transactions is available via the Medi-Cal Web site through December 2004.
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Q: Is it true that we can log on using either our three-digit submitter ID (CMCSUB***) and password or nine-digit Medi-Cal
Provider ID and PIN?
A:
Yes. You can access transactions using either your three-digit submitter ID and password or nine-digit provider ID and PIN because the
Claim Status Inquiry transaction is on both the submitter and provider menus.
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Q: Am I limited to 99 claims per batch (99 ST/SE segments) or within 1 ISA/IEA if I am checking claims
status at the claim level?
A:
There is no limit to the number of ST/SE segments you can submit. However, there is a limit of 99 responses (ST/SE segments) per
inquiry transaction.
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Q: Do the same formatting and edits that apply to dollar value fields in the 837 electronic claim transaction also apply to the
276 Inquiry transaction? (For example, no leading zeros for values less than one dollar, i.e. “.99” versus “0.99”.)
A:
With the 276 Inquiry transaction, as long as the dollar value fields contain only numbers and, at most, one decimal, it will be
accepted. An optional sign (+ or -) can precede the number, but no spaces are permitted. Spaces are not numeric values and
should not be included in a numeric field.
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Q: Will an inquiry give us the full history of a claim in chronological order, including reversals?
A:
For claims that are underpaid, then adjusted to pay more than the original claim, you will see the paid amount for the original claim
and the paid amount for the adjustment. For claims that are overpaid, then adjusted to pay less than the original claim, you will see
the paid amount for the original claim and a negative paid amount representing the money recouped by Medi-Cal. A claim that was denied
and resubmitted as a new claim will appear in the response as two separate claims. In this case, the claims are not linked for a
historical perspective, since the provider did not link them in the submission.
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Q:
I submitted the correct provider number, subscriber number, dates of service and total claim charge amount from my X12N 837
professional claim (or paper CMS 1500, LTC 25-1, Pharmacy 30-1, Vision 45-1, Outpatient UB-04
claim forms). Why am I receiving a 277 response indicating that the claim is not found (the Claim Status Code is “A4” and
the Claim Status Category Code is “35”)?
A:
Med-Cal splits some types of claims into lines and processes and pays each line as an individual claim. Due to this fact, for
non-compound Pharmacy, LTC, Outpatient, Medical and Vision claims, and when service line information (loop 2210D) is not included in
a 276 inquiry, enter the amount charged for the CLAIM LINE in the “Total Claim Charge Amount” field (AMT02 2200D Loop).
Medi-Cal processes Inpatient, Compound Pharmacy and Crossover claims at the claims level only, so for these types of claims 276
submitters should include the total amount billed for the entire claim in the “Total Claim Charge Amount” field.
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