CMS Claim Status Category and Claim Status Codes Update

May 2019 ~

CMS has released updates to the claim status and claim status category codes used for the Accredited Standards Committee (ASC) X12 276/277, Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.

According to the update, HIPAA requires all covered entities to use only Claim Status Category Codes and Claim Status Codes approved by the National Code Maintenance Committee in the ASC X12 276/277 Health Care Claim Status Request and Response transaction standards adopted under HIPAA for electronically submitting health care claims status requests and responses. These codes explain the status of submitted claim(s). CMS directs physicians, providers, and suppliers submitting claims to MACs to not use proprietary codes in the ASC X12 276/277 transactions to report claim status.

As seen in the announcement, the National Code Maintenance Committee meets at the beginning of each ASC X12 trimester meeting (January/February, June, and September/October) and makes decisions about additions, modifications, and retirement of existing codes. The Committee allows the industry 6 months for implementation of newly added or changed codes. The codes sets are available, include specific details, including the date when a code was added, changed, or deleted. All code changes approved during the June 2019 committee meeting are available on these sites on or about July 1, 2019. CMS will issue future updates to these codes as needed.

MACs must update their claims systems to ensure they use the current version of these codes in their claim status responses, by the October 7 implementation date.

MACs use these code changes in editing all ASC X12 276 transactions the MACs process on or after the implementation date and are in the ASC X12 277 transactions issued on and after the implementation date of CR11292.

MACs must comply with the requirements in the current standards adopted under HIPAA for electronically submitting certain health care transactions, among them the ASC X12 276/277 Health Care Claim Status Request and Response. The MACs must use valid Claim Status Category Codes and Claim Status Codes when sending ASC X12 277 Health Care Claim Status Responses. They must also use valid Claim Status Category Codes and Claim Status Codes when sending ASC X12 277 Healthcare Claim Acknowledgments. References in CR11292 to “277 responses” and “claim status responses” encompass both the ASC X12 277 Health Care Claim Status Response and the ASC X12 277 Healthcare Claim Acknowledgment transactions.

For more information regarding this update, refer to the official instruction, CR11292.

Source(s): CMS MLN Matters MM11292;