EDI 276

How to use an EDI 276?

The EDI 276 transaction is used by healthcare providers to electronically inquire about the status of a previously submitted claim with an insurance company or payor. Providers gather claim details such as patient information, claim number, and provider ID, then format the request according to ANSI X12 EDI 276 standards. The transaction is sent through a clearinghouse or direct EDI connection, where the payor processes the request and retrieves the claim status. The payor then responds with an EDI 277 transaction, providing details such as whether the claim has been accepted, is under review, has been rejected (with reasons), or has been paid or denied. Based on the response, providers can take appropriate action, such as submitting additional information or following up on claim status. This automated process helps streamline billing, reduce delays, and improve transparency in healthcare claims management.

What Information Does the EDI 276 Include?

The EDI 276 transaction, also known as a Healthcare Claim Status Request, is used by healthcare providers to check the status of a previously submitted claim. It typically includes the following information:

• Patient Information – Name, date of birth, gender, and member ID.
• Provider Details – Name, National Provider Identifier (NPI), and Tax Identification Number (TIN).
• Claim Information – Unique claim number, billing codes, and service details.
• Payer/Insurance Company Details – Name and identification number of the insurance company or payor.
• Date of Service – The date the medical service was provided.
• Request Reason Code – Specifies why the claim status is being requested (e.g., pending payment, denied, processed).

The insurance company or payor responds with an EDI 277 transaction, which provides claim status updates, including whether it was accepted, rejected, paid, or requires additional information.
 

HIPAA Compliance and EDI 276

As of March 31, 2012, healthcare providers must comply with HIPAA version 5010 for EDI transactions. EDI/HQ™ Healthcare software ensures full HIPAA-compliant EDI processing, offering:

• Advanced EDI translation
• Superior mapping and integration
• Enhanced data management