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

SegmentEntire Segment
ViewST*276*0001*Implementation Convention Reference
ViewBHT*0010*13*500*20200304*1349*31
ViewNM1*PR*1*ABC INSURANCE*X*T***PI*9012345918341
ViewPER*IC*ARTHUR JONES*TE*6145551212*EX*1212*FX*6145551212
ViewNM1*41*2*SMITH*****46*111222333
ViewHL*1**20*1
ViewPRV*BI*1K*3920394930203
ViewCUR*1P*004
ViewNM1*IL*1*SMITH*BARBARA*M**M.D.*SV*43202
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*BLT*12345678900987654321768958473
ViewREF*EA*500
ViewPER*IC*ARTHUR JONES*TE*1212*EX*6145551212*FX*1212
ViewNM1*QC*1
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewNM1*PR*2*SMITH*****MI*123456789
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*FJ*3920394930203
ViewREF*1K*12345678900987654321768958473
ViewHL*2*1*22*0
ViewSBR*A*18*500*ARTHUR JONES*12****11
ViewPAT*****D8*20030204*01*19991267*Y
ViewNM1*41*1*ABC INSURANCE*X*F**PH.D*PI*9012345918341
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewDMG*RD8*20030201-20030204*M
ViewREF*BLT*3920394930203
ViewREF*EA*12345678900987654321768958473
ViewPER*IC*ARTHUR JONES*TE*6145551212*EX*1212
ViewNM1*1P*2*ABC INSURANCE*****46*111222333
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*FJ*500
ViewREF*1K*3920394930203
ViewREF*BLT*12345678900987654321768958473
ViewCLM*Claim Submitter's Identifier*665.75***01+B+0*N*A*N*I*P*AA+AA++AA+004*02********1
ViewDTP*431*D8*20030204
ViewDTP*454*RD8*20030201-20030204
ViewDTP*304*D8*20030204
ViewDTP*453*RD8*20030201-20030204
ViewDTP*439*D8*20030204
ViewDTP*484*RD8*20030201-20030204
ViewDTP*455*D8*20030204
ViewDTP*471*RD8*20030201-20030204
ViewDTP*314*D8*20030204
ViewDTP*297*RD8*20030201-20030204
ViewDTP*296*D8*20030204
ViewDTP*435*RD8*20030201-20030204
ViewDTP*096*D8*20030204
ViewDTP*090*RD8*20030201-20030204
ViewDTP*090*D8*20030204
ViewDTP*444*RD8*20030201-20030204
ViewDTP*050*D8*20030204
ViewPWK*03*AA***SV*43202
ViewCN1*01*75*15665*500*268768*Version Identifier
ViewAMT*T3*665.75
ViewREF*EA*3920394930203
ViewREF*FJ*12345678900987654321768958473
ViewREF*1K*500
ViewREF*BLT*3920394930203
ViewREF*EA*12345678900987654321768958473
ViewREF*FJ*500
ViewREF*1K*3920394930203
ViewREF*BLT*12345678900987654321768958473
ViewREF*EA*500
ViewREF*FJ*3920394930203
ViewREF*1K*12345678900987654321768958473
ViewREF*BLT*500
ViewREF*EA*3920394930203
ViewREF*FJ*12345678900987654321768958473
ViewK3*Fixed Format Information
ViewNTE*ADD*Description
ViewCR1*LB*4112753**A*DH*1***Description*Description
ViewCR2********A**Description*Description
ViewCRC*07*N*01*01*01*01*01
ViewCRC*E1*N*L1*L1*L1*L1*L1
ViewCRC*E1*N*L1*L1*L1*L1*L1
ViewCRC*75*Y*IH
ViewCRC*ZZ*N*AV*AV*AV
ViewHI*BK+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000
ViewHI*BP+0001F*BO+0001F
ViewHI*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001
ViewHCP*00*75*665.75*500*2284*3920394930203*75******T1*1*1
ViewNM1*IL*1*ABC INSURANCE*X*T**M.D.*MI*123456789
ViewREF*1K*12345678900987654321768958473
ViewNM1*QC*1*ABC INSURANCE*X*M**PH.D*PI*9012345918341
ViewPRV*PE*BLT*500
ViewREF*EA*3920394930203
ViewNM1*PR*2*JONES*****46*111222333
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*FJ*12345678900987654321768958473
ViewPER*IC*ARTHUR JONES*FX*6145551212*TE*1212
ViewNM1*41*1*SMITH*BARBARA*F**M.D.*SV*43202
ViewREF*1K*500
ViewNM1*1P*2
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewNM1*IL*2*SMITH
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewSBR*A*01*3920394930203*ARTHUR JONES*12****11
ViewCAS*CO*1*665.75*1*1*75*1*1*665.75*1*1*75*1*1*665.75*1*1*75*1
ViewAMT*T3*665.75
ViewAMT*T3*75
ViewAMT*T3*665.75
ViewOI***N*P**I
ViewMOA*7*75*12345678900987654321768958473*500*3920394930203*12345678900987654321768958473*500*665.75*75
ViewNM1*QC*1*SMITH*BARBARA*T**PH.D*MI*123456789
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*BLT*3920394930203
ViewNM1*PR*2*ABC INSURANCE*****PI*9012345918341
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewDTP*573*RD8*20030201-20030204
ViewREF*EA*12345678900987654321768958473
ViewREF*FJ*500
ViewREF*1K*3920394930203
ViewREF*BLT*12345678900987654321768958473
ViewREF*EA*500
ViewNM1*41*1
ViewREF*FJ*3920394930203
ViewREF*1K*12345678900987654321768958473
ViewREF*BLT*500
ViewNM1*1P*1
ViewREF*EA*3920394930203
ViewNM1*IL*2
ViewREF*FJ*12345678900987654321768958473
ViewNM1*QC*1
ViewREF*1K*500
ViewREF*BLT*3920394930203
ViewREF*EA*12345678900987654321768958473
ViewNM1*PR*1
ViewREF*FJ*500
ViewLX*229732
ViewSV1*HC+0446T+99566+99566+99566+99566+Description*665.75*MJ*1*01**19+8+2+18**Y**Y*Y***0
ViewSV5*HC+0447T*DA*1*75*665.75*1
ViewPWK*03*AA***46*111222333
ViewPWK*CT*AB
ViewCR1*LB*19**A*DH*1***Description*Description
ViewCR3*I*MO*1
ViewCRC*07*N*01*01*01*01*01
ViewCRC*70*N*65
ViewCRC*09*N*38*38
ViewDTP*472*D8*20030204
ViewDTP*471*RD8*20030201-20030204
ViewDTP*607*D8*20030204
ViewDTP*463*RD8*20030201-20030204
ViewDTP*461*D8*20030204
ViewDTP*304*RD8*20030201-20030204
ViewDTP*738*D8*20030204
ViewDTP*011*RD8*20030201-20030204
ViewDTP*455*D8*20030204
ViewDTP*454*RD8*20030201-20030204
ViewQTY*PT*1
ViewQTY*FL*1
ViewMEA*OG*HT*282
ViewCN1*01*75*32432*3920394930203*84*Version Identifier
ViewREF*1K*12345678900987654321768958473
ViewREF*BLT*500
ViewREF*EA*3920394930203**FJ+12345678900987654321768958473
ViewREF*1K*500
ViewREF*BLT*3920394930203
ViewREF*EA*12345678900987654321768958473
ViewREF*FJ*500
ViewREF*1K*3920394930203
ViewREF*BLT*12345678900987654321768958473**EA+500
ViewAMT*T3*665.75
ViewAMT*T3*75
ViewK3*Fixed Format Information
ViewNTE*ADD*Description
ViewNTE*TPO*Description
ViewPS1*3920394930203*665.75
ViewHCP*00*75*665.75*12345678900987654321768958473*40754*500*75**HC*0001F*MJ*1*T1*1*1
ViewLIN**HC*00002060440
ViewCTP****1*F2
ViewREF*FJ*3920394930203
ViewNM1*41*1*SMITH*BARBARA*M**M.D.*SV*43202
ViewPRV*PE*1K*12345678900987654321768958473
ViewREF*BLT*500**EA+3920394930203
ViewNM1*1P*1******MI*123456789
ViewREF*FJ*12345678900987654321768958473**1K+500
ViewNM1*IL*2*JONES*****PI*9012345918341
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*BLT*3920394930203**EA+12345678900987654321768958473
ViewNM1*QC*1*ABC INSURANCE*X*F**PH.D*46*111222333
ViewREF*FJ*500**1K+3920394930203
ViewNM1*PR*1*ABC INSURANCE*X*T**M.D.*SV*43202
ViewN3*Address Information*Address Information
ViewN4*City Name*AA*00501*004
ViewREF*BLT*12345678900987654321768958473**EA+500
ViewPER*IC*ARTHUR JONES*EX*6145551212*FX*1212*TE*6145551212
ViewNM1*41*1*SMITH*BARBARA*M**PH.D*MI*123456789
ViewREF*FJ*3920394930203**1K+12345678900987654321768958473

Solutions:
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