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5010 999 and 277CA Overview For 5010 submitters the 999 transaction replaces the 997, and the 277CA transaction replaces Cahaba’s audit trails. A 999 is produced when a 5010 file is submitted, and will indicate if the file is rejected, accepted with errors, or accepted. If the file is accepted on the 999, or accepted with errors, a 277CA will be produced to indicate if the file passed front-end editing. The 277CA will provide more detail, indicating whether or not each Submitter, Billing Provider, claim, and line on each claim passed editing. The 999 and the 277CA use codes to indicate errors. This is to ensure consistency between all of the MACs. A 999 and a 277CA from Cahaba should follow the same format as these transactions from a different MAC, so that a software package that can process a Cahaba 999 and 277CA can also process these transactions from another source. This documentation is intended to provide an explanation of the 999 and the 277CA. The specifications for the 277 transaction, the 999, and the codes used for each, can be obtained online. The Washington Publishing Company’s website, at http://www.wpc-edi.com/ provides: •

Technical Type 3 (TR3) documents which provide detailed specifications for all of the 5010 transactions:

http://store.x12.org/store/healthcare-5010-consolidated-guides/ •

Claim status codes:

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ •

Claim category codes:

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/

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CMS also has resources, available at: http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp. • • •

Spreadsheets which list and give details for the edits. A side-by-side comparison of the 4010A1 and 5010 formats. Details concerning the editing process.

The 999 and the 277CA transactions are intended to be processed by an office management system to produce reports and to update data.

Providers who have questions about these transactions should contact their clearing house, billing service, or software vendor. Definition of terms Interchange—that portion of a 5010 file which occurs between the ISA and the IEA segments. Functional Group—that portion of a 5010 which occurs between the GS and GE segments. Transaction Set—that portion of a 5010 file which occurs between the ST and SE segments. Submitters who use the 5010 format may send multiple transaction sets and functional groups in an interchange. The 999 will indicate accepts and rejections at the Interchange, Functional Group, and Transaction Set level. The 277CA will indicate accepts and rejections at the submitter and billing provider level, as well as at the claim and line level. 999 Accepted Interchange Below is an example of a 999 showing an accepted interchange. The submitted interchange only contained one functional group and one transaction set. ISA*00* *00* *ZZ*10202 *110923*1507*^*00501*000000001*0*P*:~ GS*FA*10202*GA12345678*20110923*150730*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC*543*005010X222A1~ AK2*837*0001*005010X222A1~ IK5*A~ AK9*A*1*1*1~ SE*6*0001~ GE*1*1~ IEA*1*000000001~

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*ZZ*GA12345678

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The ‘A’ in the IK5 segment indicates there were no errors in the transaction set. The ‘A’ in the AK9 segment indicates there were no errors in the functional group. The submitter can expect to receive a 277CA. 999 Rejected Interchange When there are issues that cause an entire interchange to reject, a TA1 record will be created in the 999 to provide details of the edit that caused the rejection. Below is an example of a 999 with a TA1 segment. ISA*00* *00* *ZZ*10301 *111004*1403*^*00501*000000001*0*P*:~ TA1*1445554454*111003*1102*R*001~ IEA*0*000000001~

*ZZ*TN1234567

Below is a breakdown of the elements in the TA1 segment and what they mean. TA1

1445554454

111003

1102

R

001

999 Segment Identifier (Interchange Acknowledgement).

Interchange Control Number (Value from the ISA13 segment).

Interchange date.

Interchange time.

Interchange Acknowledgement Code (R = “Rejected”).

Interchange Note Code (001 = “The Interchange Control Number in the Header and Trailer Do Not Match. The Value From the Header is Used in the Acknowledgement.)”

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999R Rejected Transaction Set Below is a 999 showing a rejected transaction set: ISA*00* *00* *ZZ*10301 *110824*1403*^*00501*000000001*0*P*:~ GS*FA*10301*GA12345678*20110824*140305*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC*700000004*005010X223A2~ AK2*837*100000004*005010X223A2~ IK3*PER*12*2010*8~ IK4*2*93*2~ IK5*R*5~ AK9*R*1*1*0~ SE*8*0001~ GE*1*1~ IEA*1*000000001~

*ZZ*GA12345678

It may be necessary to use data from the IK3 and IK4 segments together to understand the error that caused the rejection. Below is a breakdown of the IK3, IK4, and IK5 segments from the above 999. IK3 999 segment ID. “Error Identification.”

PER ID of segment in error (PER segment).

IK4 999 segment ID. “Implementation Data Element Note.”

12 Position of the segment in error relative to the start of the transaction set.

2 Position of data element in error in the segment.

2010 ID of loop containing segment in error (2010 loop).

8 Syntax error code. 8 = “segment has data element errors.” See the TR3 document for the 999 transaction.

93 Data element reference number. See the Data Element Dictionary for a description.

2 Syntax Error Code. 2 = “Conditional Required Data Element Missing.”

IK5 R 5 999 segment ID. Acknowledgement Code (R Transaction Set Syntax “Transaction Set Response = “rejected”). Error Code. 5 = “One or Trailer.” More Segments in Error.” See TR3 document for 999 transaction.

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AK9 R 1 1 999 Segment Error code – R Number of Number Identifier. (Rejected). transaction sets received “Functional included. transaction Group sets. Response Trailer.”

0 of Number accepted transaction sets.

of

999E Accepted Transaction Set With Errors The example 999 below shows an ‘accept with errors.’ While the transaction set contained errors, a 277CA should still be produced. ISA*00* *00* *ZZ*10102 *110826*1306*^*00501*000000001*0*P*:~ GS*FA*10102*GA12345678*20110826*130616*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC*230426130*005010X222A1~ AK2*837*0001*005010X222A1~ IK3*CLM*31*2300*8~ IK4*6*I10~ IK5*E*5~

*ZZ*GA12345678

AK9*E*1*1*1~

SE*6*0001~ GE*1*1~ IEA*1*000000001~

In the above example the E in the IK5 segment indicates the file was accepted with errors. The submitter should receive a 277CA for this submission which will give more information regarding the errors in the file. Below is a more detailed breakdown of the above IK3, IK4, IK5, and AK9 segments from the above 999E. IK3 CLM 31 999 segment ID. ID of segment in Position of the “Error Identification error (CLM loop) segment in error relative to the start of the transaction set.

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8 Syntax Error Code. 8 = “Segment Has Data Element Errors.” See TR3 document for the 999 transaction.

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IK4 999 segment ID. “Implementation Data Element Note.” IK5 999 segment ID. “Transaction Set Response Trailer.” AK9 999 Segment Identifier. “Functional Group Response Trailer.”

6 I10 Position of the element in Syntax error code. I10 = error inside of the segment “Implementation ‘Not Used’ Data Element Present.” E 5 Error code – E = accept Transaction set syntax error with errors code. 5 = “One or More Segments in Error.”

E Error code – E = accept with errors

1 1 Number of Number of transaction sets received included transaction sets

1 Number accepted transaction sets.

of

277CA Submitter Accepted A 277CA will be produced if the 999 indicates the functional group was accepted or accepted with errors. The excerpt of a 277CA below is an example of a submitter level acceptance. ISA*00* *00* *ZZ*10302 *110914*1105*^*00501*000000001*0*T*:~ GS*HN*10302*GA12345678*20110914*110505*1*X*005010X214~ ST*277*000000001*005010X214~ BHT*0085*08*11257*20110914*110505*TH~ HL*1**20*1~ NM1*PR*2*CAHABA*****46*10302~ TRN*1*11111333111113335555555001~ DTP*050*D8*20110914~ DTP*009*D8*20110914~ HL*2*1*21*1~ NM1*41*2*INTERNAL MED ASSOC*****46*GA12345678~ TRN*2*0001~ STC*A1:19:PR*20110914*WQ*7766.00~ QTY*90*4~ QTY*AA*1~ AMT*YU*5803.00~ AMT*YY*1963.00~

*ZZ*GA12345678

The WQ in the STC segment indicates an accepted submitter level information. The QTY segments indicate the quantity of accepted and rejected claims. AMT segments indicate the accepted and rejected billed amounts. Below are more detailed breakdowns of these segments.

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STC 277CA segment identifier

A1:19:PR Claim status category code (A1 = “The claim has been received”): claim status code (19 = “Entity acknowledges receipt of claim/encounter”): entity identifier code (PR = “Payer”).

QTY 277CA segment identifier (“Total Accepted Quantity”). QTY 277CA segment identifier (“Total Rejected Quantity”). AMT 277CA segment identifier “Total Accepted Monetary Amount”). AMT 277CA segment identifier (“Total Rejected Monetary Amount”).

20110914 Effective date of the status information.

WQ Action code indicating if functional group (ST – SE envelope) was accepted (WQ = “accepted”).

90 Acknowledged quantity.

4 Total accepted quantity.

AA Unacknowledged quantity.

1 Total rejected quantity.

YU 5803.00 Amount qualifier code. (YU Total monetary amount. = “in process”) YY 1963.00 Amount qualifier code (YY Total monetary amount. = “returned”).

277CA – Example of an Accepted Claim The below excerpt from a 277CA indicates an accepted claim. HL*5*3*PT~ NM1*QC*1*BENEFICIARY*TEST*A*MI*123456789A~ TRN*2*1000893~ STC*A2:20:PR*20110914*WQ*1392.00~ REF*1K*1911290153580~ DTP*472*D8*20110816~

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7766.00 Sum of all CLM02 amounts (billed amount for claim) in the functional group.

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The WQ in the STC segment indicates the claim for ‘TEST A. BENEFICIARY’ was accepted. Below is a more detailed description of the elements in the STC segment. STC 277CA segment identifier (“Claim Level Status Information”).

A2:20:PR Claim status category code (A2 = claim accepted): claim status code (20 = “accepted for processing”): entity identifier code (PR = “Payer”).

20110914 Effective date of the status information.

WQ 1392.00 Status Total claim information charge amount. action code (WQ = “Accept”).

The Internal Control Number (ICN) for an accepted claim will appear in the REF segment. No ICN will be assigned to claims that are not accepted. REF 277CA segment identifier (Reference information segment).

1K Reference Identification Qualifier (1K = “Payer’s Claim Number”).

1911290153580 Internal Control Number assigned to claim by the payer.

277CA – Example of a Rejected Claim The 277CA excerpt below indicates a claim that was rejected. HL*4*3*PT~ NM1*QC*1*BENEFICIARY*TESTING*A***MI*123456789A~ TRN*2*T20378~ STC*A7:500:77*20110922*U*409.00~ DTP*472*D8*20110627~

The U in the STC segment indicates the claim was rejected. Below is a more detailed description of the elements in this STC segment. STC 277CA segment identifier

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A7:500:77 Claim status category code (A7 = “Rejected for Invalid Information”): Claim status code (500 =

20110922 Status information effective date.

U 409.00 Action code (U Monetary = “Reject”). amount.

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“Entity’s postal zip code”): Entity identifier code (77 = “service location”). This STC segment above indicates the claim rejected because the zip code in the service location information was invalid. 277CA Line Level Rejections A claim may also reject because of an issue with one or more of the charges on it. The 277CA excerpt below shows an example of a line-level rejection. NM1*QC*1*BENEFICIARY*TESTING****MI*987654321T~ TRN*2*31234564DDAADDD~ STC*A1:19:PR*20111018*WQ*40.00~ DTP*472*D8*20111005~ SVC*HC:Q2039*15.00*****1.000~ STC*A8:306**U~ REF*FJ*1041976~ DTP*472*D8*20111005~

Below is a breakdown of the SVC and STC segments. Empty elements, indicated by two asterisks (**), are omitted. SVC 277CA segment identifier (Service Line Information)

HC:Q2039 15.00 Composite Medical Monetary Amount. Procedure Identifier (HC = Health Care Financing Administration Common Procedural Coding System [HCPCS] codes: Product/Service ID

STC 277CA segment identifier (Service Line Level Status Information)

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1.000 Quantity.

A8:306 U Claim Status Category Code Action code (U = “Reject.”) (A8 = “Acknowledgement/Rejected for relational field in error”):Health Care Claim Status Code (“Detailed description of service”).

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In the above example, the claim rejected because the code being billed, Q2039, requires a detailed description of service, and this was not submitted.

Complete 277CA Below is an example of a complete 277CA. ISA*00* *00* *ZZ*10302 *110914*1105*^*00501*000000001*0*T*:~ GS*HN*10302*GA12345678*20110914*110505*1*X*005010X214~ ST*277*000000001*005010X214~ BHT*0085*08*11257*20110914*110505*TH~ HL*1**20*1~ NM1*PR*2*CAHABA*****46*10302~ TRN*1*1020004564444465788901~ DTP*050*D8*20110914~ DTP*009*D8*20110914~ HL*2*1*21*1~ NM1*41*2*INTERNAL MED ASSOC*****46*GA12345678~ TRN*2*0001~ Submitter STC*A1:19:PR*20110914*WQ*7766.00~ information QTY*90*4~ was QTY*AA*1~ AMT*YU*5803.00~ accepted. AMT*YY*1963.00~ HL*3*2*19*1~ NM1*85*2*INTERNAL MED ASSOC*****XX*1234567890~ TRN*1*0~ Billing STC*A1:19:PR**WQ*7766.00~ Provider QTY*QA*4~ QTY*QC*1~ information AMT*YU*5803.00~ was AMT*YY*1963.00~ HL*4*3*PT~ NM1*QC*1*BENEFICIARY*TEST*A***MI*XYA123456~ TRN*2*1000891~ Claim was STC*A7:164:IL*20110914*U*1963.00~ rejected for DTP*472*D8*20110822~ HL*5*3*PT~ claim level NM1*QC*1*BENEFICIARY*TEST*A*MI*123456789A~ edit. TRN*2*1000893~ STC*A2:20:PR*20110914*WQ*1392.00~ Claim was REF*1K*1911290153580~~ accepted. DTP*472*D8*20110816~ HL*6*3*PT~ NM1*QC*1*BENEFICIARY*MEDICARE****MI*987654321A~ TRN*2*1000898~ Claim was STC*A2:20:PR*20110914*WQ*1392.00~ REF*1K*1911290153590~~ accepted. DTP*472*D8*20110816~ HL*7*3*PT~

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*ZZ*GA12345678

11 NM1*QC*1*BENEFICIARY*TESTING*A***MI*123456789A~ TRN*2*31234564DDAADDD~ STC*A1:19:PR*20111018*WQ*40.00~ DTP*472*D8*20111005~ SVC*HC:Q2039*15.00*****1.000~ STC*A8:306**U~ Claim rejected for line REF*FJ*1041976~ level edit. DTP*472*D8*20111005~ HL*8*3*PT~ NM1*QC*1*JONES*BENEFICIARY****MI*987654321A~ TRN*2*1000907~ Claim was STC*A2:20:PR*20110914*WQ*2323.00~ accepted. REF*1K*1911290153600~~ DTP*472*D8*20110823~ SE*53*000000001~ GE*1*1~ IEA*1*000000001~

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