Is there a crosswalk to the Claim Status Codes?
- NOTE
This FAQ answer is intended to assist payers in creating crosswalks from their internal edits to claim status (277) codes. This has proven in the past to be a somewhat challenging exercise. These are only guidelines and do not constitute an X12 document.
1. The action resulting from an edit must be known prior to assigning 277 codes to payor edits. It is not possible to crosswalk codes based simply on the words of the edit. The context of the edit (i.e., which line of business it applies to) must be known as this may affect what the edit means and how it is used. The key question is: Does the edit result in action on the providers part? If not, no detail information is needed in the 277 codes as there is nothing the receiver of the 277 needs to do (see "Use of P Codes" below).
USE OF A CODES
2. A (Acknowledgement) codes are used in the 277 Unsolicited Claim Status (U-277) transaction for front end acknowledgement/rejection reporting (claims application acknowlegement)
USE OF P CODES
3. P (Pended) codes are used in the Solicited 277 (S-277) and the Unsolicited Claim Status 277 (U-277) transactions although not for the claims application acknowledgement function of the U-277.
4. If an edit results in an internal-to-payor action which is not normally communicated to an outside entity (provider, subscriber, employer, etc), use P1:41 Pending/In Process: The claim/encounter is in the adjudication system:Special handling required at payer site or P2:41 Pending/In Review:
The claim/encounter is outside of the normal adjudication system and is being reviewed (internally or externally):Special handling required at payer site to indicate that the claim has been pended for internal reasons and that no action is being required of the provider or another party.
5. If the request for information is a second or subsequent request, only P codes should be used ( R codes should be used for initial requests only). It is acknowledged that many payer systems will not have the capacity to do this initially. However, using P codes for second/subsequent requests for information gives payers the capability to parallel current paper systems which inform the provider that this is not an initial information request. Payers are encouraged to develop this capability.
USE OF R CODES
6. R (Request for Information) codes should be used in the Request For Additional Information 277 (A-277).
7. Generally R codes are used for initial information request (i.e., the first time a specific piece of information is requested). Providers need a way to automatically distinquish between initial and subsequent requests for information (see #5 above).
8. R3 Claim/Line Requests: Request for information about the claim/encounter or a specific line on the claim/encounter is for data requests that are usually included on the claim (this could vary by specialty). Generally speaking, R3 codes are used to clarify information from the claim which can be accomplised using coded data.
9. R4 Documentation Requests: Request for information where the information is not contained in the claim/encounter. This includes notes, charts, histories, EOB's, reason for treatment, medical necessity, authorizations, certifications not included in the claim, etc.) is for information that "generally" does not come in on a claim or that is not available in codiafiable format. (i.e.,. anything normally considered an attachment - this can vary by specialty).
10. As a rule R0 (General Requests: Other Requests which don't fall into one of the other three categories) should be used as a last resort when the request does not fit into any of the other R categories. In general, it should be used as little as possible.
USE OF F CODES
11. F Finalized codes are used in the Unsolicited Claim Status 277 (U-277) and in the Solicited 277 to repond to status inquiries on finalized claims. U-277 use could include front end acknowledgments, and unsolicited 277s sent on claims for which an 835 is also being generated. Many payers have, in their paper remittance advice systems, included 277 information. In order to parallel those types of paper RA systems, payers may send paired 835s and 277s. In that case, use F codes.
- NOTE
The Code Maintenance Committee may wish to create an F code which would indicate partial payment. Currently there is an F/Denied, and F/Payment, but not something in between which might indicate that the claim would re readjudicated if the information requested were to be submitted.
OTHER
12. Code 123 (additional information requested from entity) is not used when requesting information from the receiver of the 277.
13. If a detail code uses "entity", then the entity code list must be used (e.g., code 123).
14. One STC is equal to a single request for information. The end of an STC segment constitutes a "." in the coded sentence. If information requests appear to need more than one STC segment to make "sense", then contact the Code Maintenance Committee (see Washington Publishing Company web site: http://www.wpc-edi.com).
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