MN–ITS Help – 277 Claim Status Response for 837D, 837I, 837P

The table below describes the individual fields on the Validate Response. * The Field Name column identifies X12 loops and elements when one exists in the 5010 ASC X12 Guide. Refer to the X12 HIPAA Companion Guides available through the WPC X12 Registry for additional instruction when submitting batch claims and request claim status.

Select MN–ITS User Manual to find information on all of the features within MN–ITS. Select Direct Data Entry (DDE) to obtain the appropriate MN–ITS User Guide for additional instruction for submitting claim requests and request claim status using MN–ITS Direct Data Entry (DDE).

Field Name *
(X12 Loop & element)

Character Length

Field Description

Receiver NPI/UMPI, Name
(Loop: 2100B, NM109, NM104, NM103)

2/80
(alphanumeric)
1/35
(alpha)
1/60
(alpha)

The entity requesting the claim status.

Provider NPI/UMPI, Name
(Loop: 2100C, NM109, NM104, NM103)

2/80
(alphanumeric)
1/35
(alpha)
1/60
(alpha)

Billing Provider NPI/UMPI and individual or organizational name receiving the reimbursement for the claim submitted.

Subscriber ID Number, Name, Patient Control Number
(Loop: 2100D, NM109, NM104, NM103, 2200D, TRN02)

8
(numeric)
1/35
(alpha)
1/60
(alpha)
1/50
(alphanumeric)

8-digit MHCP member ID. The member’s last and first name. A unique identifier, assigned by the provider, which will be reported on the remittance advice to help identify this claim for this member.

Claim Information

Bill Type
(Loop: 2200D, REF03, REF02)

6/12
(alpha)

Code indicating the specific type of billing claim form:

  • Dental
  • Professional
  • Intuitional

Status Info Effective Date
(Loop: 2200D, STC02)

10
(numeric)

The date the claim was submitted using the submit action button.

Total Claim Charge Amount
(Loop: 2200D, STC04)

1/18
(numeric)

The sum of all the charges submitted on the claim.

Claim Payment Amount
(Loop: 2200D, STC05)

1/18
(numeric)

Net reimbursement amount for the billing or paid-to provider.

Adjudication Date
(Loop: 2200D, STC06)

8/8
(numeric)

The date the claim was submitted for processing.

Remittance Date
(Loop: 2200D, STC08)

8/8
(numeric)

The date the claim was paid by MHCP.

Trace Number
(Loop: 2200D, REF02)

1/50
(alphanumeric)

The electronic funds transfer (EFT) or paper check warrant number of the payment for this claim.

Service Period
(Loop: 2200D, DTP03)

1/35
(numeric)

Service period begin and end dates entered in the search criteria.

Payer Claim Control Number
(Loop: 2200D REF02)

17/17
(numeric)

Number assigned by MHCP to identify this claim.

Pharmacy Prescription Number
(Loop: 2200D, REF02)

1/60
(numeric)

Pharmacy Prescription Number that was submitted on the claim. Used by pharmacies to identify this claim.

Claim Status Category Code
(Loop: 2200D, STC010-1)

2/3
(alphanumeric)

Washington Publishing Company HIPAA compliant claim status category codes that indicate the general status of the claim (accepted, rejected, additional information, internal review is needed, etc.).

Claim Status Code
(Loop: 2200D, STC010-2)

1/3
(alphanumeric)

Washington Publishing Company HIPAA compliant claim status codes that indicate the specific status of the claim.

Service Line Information
(If multiple lines, select each accordion panel to display the following fields.)

Service Dates
(Loop: 2220D, DTP03)

1/35
(numeric)

A date or a range of dates for the service performed.

Modifier
(Loop: 2400, SV101-3, SV101-4, SV101-5, SV101-6)

2
(alphanumeric)

The modifier(s) submitted on the line, which clarifies or further identifies the service.

Charge
(Loop: 2400, SV102)

10
(numeric)

The total charge for the service submitted on the line.

Payment
(Loop: 2220D, SVC03)

1/18
(numeric)

Amount of payment for the service line.

Revenue Code
(Loop: 2220D, SVC04)

1/48
(alphanumeric)

National Uniform Billing Committee (NUBC) revenue code that describes the service performed.

Status Information Effective Date
(Loop: 2220D, STC02)

8/8
(numeric)

The date the claim was submitted for processing.

Claim Status Category Code
(Loop: 2200D, STC011-1)

2/3
(alphanumeric)

Washington Publishing Company HIPAA compliant claim status category codes that indicate the general status of the service line (pending adjudication, pending internal review, paid or denied).

Claim Status Code
(Loop:2200D, STC011-2)

1/3
(alphanumeric)

Washington Publishing Company HIPAA compliant claim status codes that indicate the specific status of the service line.

Screen Action Buttons

 

Select:

  • Copy to begin a new 837 claim entry, populated with information identical to this claim. Edit information in each claim section, as needed, to create a unique claim.
  • Replace to begin an 837 replacement claim entry for this claim. Edit information in each claim section, as needed, to correct any claim data. The original paid amount for this claim will be taken back and replaced with the payment for the replacement claim.
  • Void (take back) to begin an 837 void claim entry for this claim. The original paid amount for this claim will be taken back.
  • Close to return to Request Claim Status screen.