Sample EDI 276 Data for the Health Care Claim Status Request Transaction Set


AgencySet IDFGTransaction DescriptionSubcommittee
ANSI276HRHealth Care Claim Status Request Insurance


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Below is a sample EDI 276 transaction set. The Jobisez.com site has an online translation tool that converts the EDI 276 (Health Care Claim Status Request) document into a CSV file. You can also gain knowledge by researching all EDI Document Types. Jobisez LLC can also provide assistance if you need additional help.

Sample of an EDI 276 Transaction Set

Entire Segment
ST*276*0001*Implementation Convention Reference
BHT*0010*13*500*20200304*1349*31
NM1*PR*1*ABC INSURANCE*X*T***PI*9012345918341
PER*IC*ARTHUR JONES*TE*6145551212*EX*1212*FX*6145551212
NM1*41*2*SMITH*****46*111222333
HL*1**20*1
PRV*BI*1K*3920394930203
CUR*1P*004
NM1*IL*1*SMITH*BARBARA*M**M.D.*SV*43202
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*BLT*12345678900987654321768958473
REF*EA*500
PER*IC*ARTHUR JONES*TE*1212*EX*6145551212*FX*1212
NM1*QC*1
N3*Address Information*Address Information
N4*City Name*AA*00501*004
NM1*PR*2*SMITH*****MI*123456789
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*FJ*3920394930203
REF*1K*12345678900987654321768958473
HL*2*1*22*0
SBR*A*18*500*ARTHUR JONES*12****11
PAT*****D8*20030204*01*19991267*Y
NM1*41*1*ABC INSURANCE*X*F**PH.D*PI*9012345918341
N3*Address Information*Address Information
N4*City Name*AA*00501*004
DMG*RD8*20030201-20030204*M
REF*BLT*3920394930203
REF*EA*12345678900987654321768958473
PER*IC*ARTHUR JONES*TE*6145551212*EX*1212
NM1*1P*2*ABC INSURANCE*****46*111222333
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*FJ*500
REF*1K*3920394930203
REF*BLT*12345678900987654321768958473
CLM*Claim Submitter's Identifier*665.75***01+B+0*N*A*N*I*P*AA+AA++AA+004*02**
DTP*431*D8*20030204
DTP*454*RD8*20030201-20030204
DTP*304*D8*20030204
DTP*453*RD8*20030201-20030204
DTP*439*D8*20030204
DTP*484*RD8*20030201-20030204
DTP*455*D8*20030204
DTP*471*RD8*20030201-20030204
DTP*314*D8*20030204
DTP*297*RD8*20030201-20030204
DTP*296*D8*20030204
DTP*435*RD8*20030201-20030204
DTP*096*D8*20030204
DTP*090*RD8*20030201-20030204
DTP*090*D8*20030204
DTP*444*RD8*20030201-20030204
DTP*050*D8*20030204
PWK*03*AA***SV*43202
CN1*01*75*15665*500*268768*Version Identifier
AMT*T3*665.75
REF*EA*3920394930203
REF*FJ*12345678900987654321768958473
REF*1K*500
REF*BLT*3920394930203
REF*EA*12345678900987654321768958473
REF*FJ*500
REF*1K*3920394930203
REF*BLT*12345678900987654321768958473
REF*EA*500
REF*FJ*3920394930203
REF*1K*12345678900987654321768958473
REF*BLT*500
REF*EA*3920394930203
REF*FJ*12345678900987654321768958473
K3*Fixed Format Information
NTE*ADD*Description
CR1*LB*4112753**A*DH*1***Description*Description
CR2********A**Description*Description
CRC*07*N*01*01*01*01*01
CRC*E1*N*L1*L1*L1*L1*L1
CRC*E1*N*L1*L1*L1*L1*L1
CRC*75*Y*IH
CRC*ZZ*N*AV*AV*AV
HI*BK+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF
HI*BP+0001F*BO+0001F
HI*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG
HCP*00*75*665.75*500*2284*3920394930203*75******T1*1*1
NM1*IL*1*ABC INSURANCE*X*T**M.D.*MI*123456789
REF*1K*12345678900987654321768958473
NM1*QC*1*ABC INSURANCE*X*M**PH.D*PI*9012345918341
PRV*PE*BLT*500
REF*EA*3920394930203
NM1*PR*2*JONES*****46*111222333
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*FJ*12345678900987654321768958473
PER*IC*ARTHUR JONES*FX*6145551212*TE*1212
NM1*41*1*SMITH*BARBARA*F**M.D.*SV*43202
REF*1K*500
NM1*1P*2
N3*Address Information*Address Information
N4*City Name*AA*00501*004
NM1*IL*2*SMITH
N3*Address Information*Address Information
N4*City Name*AA*00501*004
SBR*A*01*3920394930203*ARTHUR JONES*12****11
CAS*CO*1*665.75*1*1*75*1*1*665.75*1*1*75*1*1*665.75*1*1*75*1
AMT*T3*665.75
AMT*T3*75
AMT*T3*665.75
OI***N*P**I
MOA*7*75*12345678900987654321768958473*500*3920394930203*12345678900987654321
NM1*QC*1*SMITH*BARBARA*T**PH.D*MI*123456789
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*BLT*3920394930203
NM1*PR*2*ABC INSURANCE*****PI*9012345918341
N3*Address Information*Address Information
N4*City Name*AA*00501*004
DTP*573*RD8*20030201-20030204
REF*EA*12345678900987654321768958473
REF*FJ*500
REF*1K*3920394930203
REF*BLT*12345678900987654321768958473
REF*EA*500
NM1*41*1
REF*FJ*3920394930203
REF*1K*12345678900987654321768958473
REF*BLT*500
NM1*1P*1
REF*EA*3920394930203
NM1*IL*2
REF*FJ*12345678900987654321768958473
NM1*QC*1
REF*1K*500
REF*BLT*3920394930203
REF*EA*12345678900987654321768958473
NM1*PR*1
REF*FJ*500
LX*229732
SV1*HC+0446T+99566+99566+99566+99566+Description*665.75*MJ*1*01**19+8+2+18**Y
SV5*HC+0447T*DA*1*75*665.75*1
PWK*03*AA***46*111222333
PWK*CT*AB
CR1*LB*19**A*DH*1***Description*Description
CR3*I*MO*1
CRC*07*N*01*01*01*01*01
CRC*70*N*65
CRC*09*N*38*38
DTP*472*D8*20030204
DTP*471*RD8*20030201-20030204
DTP*607*D8*20030204
DTP*463*RD8*20030201-20030204
DTP*461*D8*20030204
DTP*304*RD8*20030201-20030204
DTP*738*D8*20030204
DTP*011*RD8*20030201-20030204
DTP*455*D8*20030204
DTP*454*RD8*20030201-20030204
QTY*PT*1
QTY*FL*1
MEA*OG*HT*282
CN1*01*75*32432*3920394930203*84*Version Identifier
REF*1K*12345678900987654321768958473
REF*BLT*500
REF*EA*3920394930203**FJ+12345678900987654321768958473
REF*1K*500
REF*BLT*3920394930203
REF*EA*12345678900987654321768958473
REF*FJ*500
REF*1K*3920394930203
REF*BLT*12345678900987654321768958473**EA+500
AMT*T3*665.75
AMT*T3*75
K3*Fixed Format Information
NTE*ADD*Description
NTE*TPO*Description
PS1*3920394930203*665.75
HCP*00*75*665.75*12345678900987654321768958473*40754*500*75**HC*0001F*MJ*1*T1
LIN**HC*00002060440
CTP****1*F2
REF*FJ*3920394930203
NM1*41*1*SMITH*BARBARA*M**M.D.*SV*43202
PRV*PE*1K*12345678900987654321768958473
REF*BLT*500**EA+3920394930203
NM1*1P*1******MI*123456789
REF*FJ*12345678900987654321768958473**1K+500
NM1*IL*2*JONES*****PI*9012345918341
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*BLT*3920394930203**EA+12345678900987654321768958473
NM1*QC*1*ABC INSURANCE*X*F**PH.D*46*111222333
REF*FJ*500**1K+3920394930203
NM1*PR*1*ABC INSURANCE*X*T**M.D.*SV*43202
N3*Address Information*Address Information
N4*City Name*AA*00501*004
REF*BLT*12345678900987654321768958473**EA+500
PER*IC*ARTHUR JONES*EX*6145551212*FX*1212*TE*6145551212
NM1*41*1*SMITH*BARBARA*M**PH.D*MI*123456789
REF*FJ*3920394930203**1K+12345678900987654321768958473

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