EDI 277 Data Transformation Documentation

EDI 277 Data Transformation

Create and transform EDI messages using the JSON format of the EDI.

Our current supported EDI version: 005010

Need help with some of our documentation? Feel free to contact our support team, and one of our support team members will be happy to assist you.

EDI 277 Request to JSON Response

Transforms an EDI 277 message into JSON.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/edi277-to-json

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request (Claim Status)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X212~ST*277*0001*005010X212~BHT*0010*08*277X212*20050916*0810*DG~HL*1**20*1~NM1*PR*2*ABC INSURANCE*****PI*12345~HL*2*1*21*1~NM1*41*2*XYZ SERVICE*****46*X67E~HL*3*2*19*1~NM1*1P*2*HOME HOSPITAL*****XX*1666666661~HL*4*3*22*0~NM1*IL*1*SMITH*FRED****MI*123456789A~TRN*2*ABCXYZ1~STC*P3:317*20050913**8513.88~REF*1K*05347006051~REF*BLT*111~REF*EJ*SM123456~DTP*472*RD8*20050831-20050906~HL*5*3*22*0~NM1*IL*1*JONES*MARY****MI*234567890A~TRN*2*ABCXYZ2~STC*F0:3*20050915**7599*7599~REF*1K*0529675341~REF*BLT*111~REF*EJ*JO234567~DTP*472*RD8*20050731-20050809~HL*6*2*19*1~NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~HL*7*6*22*1~NM1*IL*1*MANN*JOHN****MI*345678901~HL*8*7*23~NM1*QC*1*MANN*JOSEPH~TRN*2*ABCXYC3~STC*F2:88:QC*20050612**150*0~REF*1K*051681010827~REF*EJ*MA345678~SVC*HC:99203*150*0****1~STC*F2:88:QC*20050612~DTP*472*D8*20050501~SE*38*0001~GE*2*1~IEA*1*161130044~

Sample response (Claim Status)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X212"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X212"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0010",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277X212",
            "BHT_04_Date_DT": "20050916",
            "BHT_05_Time_TM": "0810",
            "BHT_06_TransactionTypeCode_ID": "DG"
          },
          "InformationSourceLevel_Loop_2000A": [
            {
              "InformationSourceLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "PayerName_Loop_2100A": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "12345",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerContactInformation": null
              },
              "InformationReceiverLevel_Loop_2000B": [
                {
                  "InformationReceiverLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "2",
                    "HL_02_HierarchicalParentIDNumber_AN": "1",
                    "HL_03_HierarchicalLevelCode_ID": "21",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "InformationReceiverName_Loop_2100B": {
                    "InformationReceiverName": {
                      "NM1_01_EntityIdentifierCode_ID": "41",
                      "NM1_02_EntityTypeQualifier_ID": "2",
                      "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICE",
                      "NM1_04_NameFirst_AN": null,
                      "NM1_05_NameMiddle_AN": null,
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": null,
                      "NM1_08_IdentificationCodeQualifier_ID": "46",
                      "NM1_09_IdentificationCode_AN": "X67E",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "InformationReceiverTraceIdentifier_Loop_2200B": {
                    "InformationReceiverTraceIdentifier": null,
                    "InformationReceiverStatusInformation": null
                  },
                  "ServiceProviderLevel_Loop_2000C": [
                    {
                      "ServiceProviderLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "3",
                        "HL_02_HierarchicalParentIDNumber_AN": "2",
                        "HL_03_HierarchicalLevelCode_ID": "19",
                        "HL_04_HierarchicalChildCode_ID": "1"
                      },
                      "ProviderName_Loop_2100C": [
                        {
                          "ProviderName": {
                            "NM1_01_EntityIdentifierCode_ID": "1P",
                            "NM1_02_EntityTypeQualifier_ID": "2",
                            "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL",
                            "NM1_04_NameFirst_AN": null,
                            "NM1_05_NameMiddle_AN": null,
                            "NM1_06_NamePrefix_AN": null,
                            "NM1_07_NameSuffix_AN": null,
                            "NM1_08_IdentificationCodeQualifier_ID": "XX",
                            "NM1_09_IdentificationCode_AN": "1666666661",
                            "NM1_10_EntityRelationshipCode_ID": null,
                            "NM1_11_EntityIdentifierCode_ID": null,
                            "NM1_12_NameLastOrOrganizationName_AN": null
                          }
                        }
                      ],
                      "ProviderOfServiceTraceIdentifier_Loop_2200C": {
                        "ProviderOfServiceTraceIdentifier": null,
                        "ProviderStatusInformation": null
                      },
                      "SubscriberLevel_Loop_2000D": [
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "4",
                            "HL_02_HierarchicalParentIDNumber_AN": "3",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "0"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                              "NM1_04_NameFirst_AN": "FRED",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "123456789A",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYZ1",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "P3",
                                    "C043_02_IndustryCode_AN": "317",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050913",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "8513.88",
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "05347006051",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                                "REF_02_ReferenceIdentification_AN": "111",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "SM123456",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                                "DTP_03_DateTimePeriod_AN": "20050831-20050906"
                              },
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        },
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "5",
                            "HL_02_HierarchicalParentIDNumber_AN": "3",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "0"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                              "NM1_04_NameFirst_AN": "MARY",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "234567890A",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYZ2",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "F0",
                                    "C043_02_IndustryCode_AN": "3",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050915",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "7599",
                                  "STC_05_MonetaryAmount_R": "7599",
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "0529675341",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                                "REF_02_ReferenceIdentification_AN": "111",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "JO234567",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                                "DTP_03_DateTimePeriod_AN": "20050731-20050809"
                              },
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ],
                      "DependentLevel_Loop_2000E": [
                        {
                          "DependentLevel": null,
                          "DependentName_Loop_2100E": {
                            "DependentName": null
                          },
                          "ClaimStatusTrackingNumber_Loop_2200E": [
                            {
                              "ClaimStatusTrackingNumber": null,
                              "ClaimLevelStatusInformation": null,
                              "PayerClaimControlNumber": null,
                              "InstitutionalBillTypeIdentification": null,
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220E": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "ServiceProviderLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "2",
                        "HL_03_HierarchicalLevelCode_ID": "19",
                        "HL_04_HierarchicalChildCode_ID": "1"
                      },
                      "ProviderName_Loop_2100C": [
                        {
                          "ProviderName": {
                            "NM1_01_EntityIdentifierCode_ID": "1P",
                            "NM1_02_EntityTypeQualifier_ID": "2",
                            "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL PHYSICIANS",
                            "NM1_04_NameFirst_AN": null,
                            "NM1_05_NameMiddle_AN": null,
                            "NM1_06_NamePrefix_AN": null,
                            "NM1_07_NameSuffix_AN": null,
                            "NM1_08_IdentificationCodeQualifier_ID": "XX",
                            "NM1_09_IdentificationCode_AN": "1666666666",
                            "NM1_10_EntityRelationshipCode_ID": null,
                            "NM1_11_EntityIdentifierCode_ID": null,
                            "NM1_12_NameLastOrOrganizationName_AN": null
                          }
                        }
                      ],
                      "ProviderOfServiceTraceIdentifier_Loop_2200C": {
                        "ProviderOfServiceTraceIdentifier": null,
                        "ProviderStatusInformation": null
                      },
                      "SubscriberLevel_Loop_2000D": [
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "7",
                            "HL_02_HierarchicalParentIDNumber_AN": "6",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "1"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "MANN",
                              "NM1_04_NameFirst_AN": "JOHN",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "345678901",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": null,
                              "ClaimLevelStatusInformation": null,
                              "PayerClaimControlNumber": null,
                              "InstitutionalBillTypeIdentification": null,
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ],
                      "DependentLevel_Loop_2000E": [
                        {
                          "DependentLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "8",
                            "HL_02_HierarchicalParentIDNumber_AN": "7",
                            "HL_03_HierarchicalLevelCode_ID": "23",
                            "HL_04_HierarchicalChildCode_ID": null
                          },
                          "DependentName_Loop_2100E": {
                            "DependentName": {
                              "NM1_01_EntityIdentifierCode_ID": "QC",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "MANN",
                              "NM1_04_NameFirst_AN": "JOSEPH",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": null,
                              "NM1_09_IdentificationCode_AN": null,
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200E": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYC3",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "F2",
                                    "C043_02_IndustryCode_AN": "88",
                                    "C043_03_EntityIdentifierCode_ID": "QC",
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050612",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "150",
                                  "STC_05_MonetaryAmount_R": "0",
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "051681010827",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "MA345678",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220E": [
                                {
                                  "ServiceLineInformation": {
                                    "SVC_01_CompositeMedicalProcedureIdentifier": {
                                      "C003_01_ProductServiceIDQualifier_ID": "HC",
                                      "C003_02_ProductServiceID_AN": "99203",
                                      "C003_03_ProcedureModifier_AN": null,
                                      "C003_04_ProcedureModifier_AN": null,
                                      "C003_05_ProcedureModifier_AN": null,
                                      "C003_06_ProcedureModifier_AN": null,
                                      "C003_07_Description_AN": null,
                                      "C003_08_ProductServiceID_AN": null
                                    },
                                    "SVC_02_MonetaryAmount_R": "150",
                                    "SVC_03_MonetaryAmount_R": "0",
                                    "SVC_04_ProductServiceId_AN": null,
                                    "SVC_05_Quantity_R": null,
                                    "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                    "SVC_07_Quantity_R": "1"
                                  },
                                  "ServiceLineStatusInformation": [
                                    {
                                      "STC_01_HealthClaimStatus": {
                                        "C043_01_IndustryCode_AN": "F2",
                                        "C043_02_IndustryCode_AN": "88",
                                        "C043_03_EntityIdentifierCode_ID": "QC",
                                        "C043_04_CodeListQualifierCode_ID": null
                                      },
                                      "STC_02_Date_DT": "20050612",
                                      "STC_03_ActionCode_ID": null,
                                      "STC_04_MonetaryAmount_R": null,
                                      "STC_05_MonetaryAmount_R": null,
                                      "STC_06_Date_DT": null,
                                      "STC_07_PAymentMethodCode_ID": null,
                                      "STC_08_Date_DT": null,
                                      "STC_09_CheckNumber_AN": null,
                                      "STC_10_HealthCareClaimStatus": null,
                                      "STC_11_HealthCareClaimStatus": null,
                                      "STC_12_FreeformMessageText_AN": null
                                    }
                                  ],
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": {
                                    "DTP_01_DateTimeQualifier_ID": "472",
                                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                                    "DTP_03_DateTimePeriod_AN": "20050501"
                                  }
                                }
                              ]
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "38",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample request (Claim Status with Additional Information)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X213~ST*277*1001*005010X213~BHT*0085*48*277X213000001*20060824*1211*RQ~HL*1**20*1~NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~PER*IC*MEDICAL REVIEW DEPARTMENT*FX*7771114321*TE*5555555555~HL*2*1*21*1~NM1*41*2*XYZ SERVICES*****46*A222222221~HL*3*2*19*1~NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*1666666666~HL*4*3*PT~NM1*QC*1*JACKSON*JACK*J***MI*987654320~TRN*1*1822634840~STC*R4:18594-2:20060824:LOI*20060824~REF*BLT*111~REF*EJ*JACKSON123~REF*EA*STHHL12345~DTP*472*D8*20060812~DTP*106*D8*20060923~SE*19*1001~GE*2*1~IEA*1*161130044~

Sample response (Claim Status with Additional Information)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X213"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "1001",
            "ST_03_ImplementationConventionReference_AN": "005010X213"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "48",
            "BHT_03_ReferenceIdentification_AN": "277X213000001",
            "BHT_04_Date_DT": "20060824",
            "BHT_05_Time_TM": "1211",
            "BHT_06_TransactionTypeCode_ID": "RQ"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "PayerName_Loop_2100A": {
              "PayerName": {
                "NM1_01_EntityIdentifierCode_ID": "PR",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE COMPANY",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "XV",
                "NM1_09_IdentificationCode_AN": "12345",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              },
              "PayerContactInformation": {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "MEDICAL REVIEW DEPARTMENT",
                "PER_03_CommunicationNumberQualifier_ID": "FX",
                "PER_04_CommunicationNumber_AN": "7771114321",
                "PER_05_CommunicationNumberQualifier_ID": "TE",
                "PER_06_CommunicationNumber_AN": "5555555555",
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "41",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "A222222221",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "ServiceProviderLevel_Loop_2000C": [
                {
                  "ServiceProviderLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "ServiceProviderName_Loop_2100C": [
                    {
                      "ProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "1P",
                        "NM1_02_EntityTypeQualifier_ID": "2",
                        "NM1_03_NameLastOrOrganizationName_AN": "ST HOLY HILLS HOSPITAL",
                        "NM1_04_NameFirst_AN": null,
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "1666666666",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      }
                    }
                  ],
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JACKSON",
                          "NM1_04_NameFirst_AN": "JACK",
                          "NM1_05_NameMiddle_AN": "J",
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "987654320",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "PayerClaimControlNumber_Loop_2200D": [
                        {
                          "PayerClaimControlNumber": {
                            "TRN_01_TraceTypeCode_ID": "1",
                            "TRN_02_ReferenceIdentification_AN": "1822634840",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "R4",
                                "C043_02_IndustryCode_AN": "18594-2",
                                "C043_03_EntityIdentifierCode_ID": "20060824",
                                "C043_04_CodeListQualifierCode_ID": "LOI"
                              },
                              "STC_02_Date_DT": "20060824",
                              "STC_03_ActionCode_ID": null,
                              "STC_04_MonetaryAmount_R": null,
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PatientControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                            "REF_02_ReferenceIdentification_AN": "111",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "InstitutionalTypeOfBill": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                            "REF_02_ReferenceIdentification_AN": "JACKSON123",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "MedicalRecordIdentificationNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "EA",
                            "REF_02_ReferenceIdentification_AN": "STHHL12345",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "ClaimServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060812"
                          },
                          "ResponseDueDate": {
                            "DTP_01_DateTimeQualifier_ID": "106",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060923"
                          },
                          "ClaimSupplementalInformation_Loop_2210D": {
                            "ClaimSupplementalInformation": null,
                            "PayerResponseContactInformation": null,
                            "PayerResponseContactAddress": null,
                            "PayerResponseContactCityStateZipCode": null
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "19",
            "SE_02_TransactionSetControlNumber_AN": "1001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample request (Claim Acknowledgment)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X214~ST*277*0001*005010X214~BHT*0085*08*277X2140001*20060205*1635*TH~HL*1**20*1~NM1*AY*2*FIRST CLEARINGHOUSE*****46*CLHR00~TRN*1*200102051635S00001ABCDEF~DTP*050*D8*20060205~DTP*009*D8*20060205~HL*2*1*21*1~NM1*41*2*BEST BILLING SERVICE*****46*S00001~TRN*2*2002020542857~STC*A0:16:PR*20060205*WQ*1000~QTY*90*1~QTY*AA*2~AMT*YU*200~AMT*YY*800~HL*3*2*19*1~NM1*85*2*SMITH CLINIC*****FI*123456789~HL*4*3*PT~NM1*QC*1*DOE*JOHN****MI*00ABCD1234~TRN*2*DOE01428~STC*A0:16:PR*20060205*WQ*200~REF*1K*22029500123407X~DTP*472*RD8*20060128-20060131~HL*5*3*PT~NM1*QC*1*DOE*JANE****MI*45613027602~TRN*2*DOE0221~STC*A3:21:82*20060205*U*500~DTP*472*D8*20060115~SVC*HC:22305:22*350*****1~STC*A3:122**U*******A3:153:82~REF*FJ*11~HL*6*3*PT~NM1*QC*1*VEST*HELEN****MI*45602708901~TRN*2*VEST0303~STC*A3:401*20060205*U*300~DTP*472*RD8*20060120-20060120~SE*37*0001~SE*9*0001~GE*2*1~IEA*1*161130044~

Sample response (Claim Acknowledgment)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X214"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X214"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277X2140001",
            "BHT_04_Date_DT": "20060205",
            "BHT_05_Time_TM": "1635",
            "BHT_06_TransactionTypeCode_ID": "TH"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationSourceName_Loop_2100A": {
              "InformationSourceName": {
                "NM1_01_EntityIdentifierCode_ID": "AY",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "FIRST CLEARINGHOUSE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "CLHR00",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            },
            "TransmissionReceiptControlIdentifier_Loop_2200A": {
              "TransmissionReceiptControlIdentifier": {
                "TRN_01_TraceTypeCode_ID": "1",
                "TRN_02_ReferenceIdentification_AN": "200102051635S00001ABCDEF",
                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                "TRN_04_ReferenceIdentification_AN": null
              },
              "InformationSourceReceiptDate": {
                "DTP_01_DateTimeQualifier_ID": "050",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20060205"
              },
              "InformationSourceProcessDate": {
                "DTP_01_DateTimeQualifier_ID": "009",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20060205"
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "41",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "BEST BILLING SERVICE",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "S00001",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "InformationReceiverApplicationTraceIdentifier_Loop_2200B": {
                "InformationReceiverApplicationTraceIdentifier": {
                  "TRN_01_TraceTypeCode_ID": "2",
                  "TRN_02_ReferenceIdentification_AN": "2002020542857",
                  "TRN_03_OriginatingCompanyIdentifier_AN": null,
                  "TRN_04_ReferenceIdentification_AN": null
                },
                "InformationReceiverStatusInformation": [
                  {
                    "STC_01_HealthClaimStatus": {
                      "C043_01_IndustryCode_AN": "A0",
                      "C043_02_IndustryCode_AN": "16",
                      "C043_03_EntityIdentifierCode_ID": "PR",
                      "C043_04_CodeListQualifierCode_ID": null
                    },
                    "STC_02_Date_DT": "20060205",
                    "STC_03_ActionCode_ID": "WQ",
                    "STC_04_MonetaryAmount_R": "1000",
                    "STC_05_MonetaryAmount_R": null,
                    "STC_06_Date_DT": null,
                    "STC_07_PAymentMethodCode_ID": null,
                    "STC_08_Date_DT": null,
                    "STC_09_CheckNumber_AN": null,
                    "STC_10_HealthCareClaimStatus": null,
                    "STC_11_HealthCareClaimStatus": null,
                    "STC_12_FreeformMessageText_AN": null
                  }
                ],
                "TotalAcceptedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "90",
                  "QTY_02_Quantity_R": "1",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalRejectedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "AA",
                  "QTY_02_Quantity_R": "2",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalAcceptedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YU",
                  "AMT_02_MonetaryAmount_R": "200",
                  "AMT_03_CreditDebitFlagCode_ID": null
                },
                "TotalRejectedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YY",
                  "AMT_02_MonetaryAmount_R": "800",
                  "AMT_03_CreditDebitFlagCode_ID": null
                }
              },
              "BillingProviderOfServiceLevel_Loop_2000C": [
                {
                  "BillingProviderOfServiceLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingProviderName_Loop_2100C": [
                    {
                      "BillingProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "85",
                        "NM1_02_EntityTypeQualifier_ID": "2",
                        "NM1_03_NameLastOrOrganizationName_AN": "SMITH CLINIC",
                        "NM1_04_NameFirst_AN": null,
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "FI",
                        "NM1_09_IdentificationCode_AN": "123456789",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      }
                    }
                  ],
                  "ProviderOfServiceInformationTraceIdentifier_Loop_2200C": {
                    "ProviderOfServiceInformationTraceIdentifier": null,
                    "BillingProviderStatusInformation": null,
                    "ProviderSecondaryIdentifier": null,
                    "TotalAcceptedQuantity": null,
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": null,
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                          "NM1_04_NameFirst_AN": "JOHN",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "00ABCD1234",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "DOE01428",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A0",
                                "C043_02_IndustryCode_AN": "16",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "200",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "22029500123407X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                            "DTP_03_DateTimePeriod_AN": "20060128-20060131"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "5",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                          "NM1_04_NameFirst_AN": "JANE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "45613027602",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "DOE0221",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A3",
                                "C043_02_IndustryCode_AN": "21",
                                "C043_03_EntityIdentifierCode_ID": "82",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "500",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": null,
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060115"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": {
                                "SVC_01_CompositeMedicalProcedureIdentifier": {
                                  "C003_01_ProductServiceIDQualifier_ID": "HC",
                                  "C003_02_ProductServiceID_AN": "22305",
                                  "C003_03_ProcedureModifier_AN": "22",
                                  "C003_04_ProcedureModifier_AN": null,
                                  "C003_05_ProcedureModifier_AN": null,
                                  "C003_06_ProcedureModifier_AN": null,
                                  "C003_07_Description_AN": null,
                                  "C003_08_ProductServiceID_AN": null
                                },
                                "SVC_02_MonetaryAmount_R": "350",
                                "SVC_03_MonetaryAmount_R": null,
                                "SVC_04_ProductServiceId_AN": null,
                                "SVC_05_Quantity_R": null,
                                "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                "SVC_07_Quantity_R": "1"
                              },
                              "ServiceLineLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "A3",
                                    "C043_02_IndustryCode_AN": "122",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": null,
                                  "STC_03_ActionCode_ID": "U",
                                  "STC_04_MonetaryAmount_R": null,
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": {
                                    "C043_01_IndustryCode_AN": "A3",
                                    "C043_02_IndustryCode_AN": "153",
                                    "C043_03_EntityIdentifierCode_ID": "82",
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "ServiceLineItemIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "FJ",
                                "REF_02_ReferenceIdentification_AN": "11",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "VEST",
                          "NM1_04_NameFirst_AN": "HELEN",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "45602708901",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "VEST0303",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A3",
                                "C043_02_IndustryCode_AN": "401",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "300",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": null,
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                            "DTP_03_DateTimePeriod_AN": "20060120-20060120"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "37",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": null
    }
  ],
  "InterchangeControlTrailerSegment": null
}

Sample request (Claim Pending Status)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X228~ST*277*0001*005010X228~BHT*0085*08*277PEND123*20070210*1635*NO~HL*1**20*1~NM1*PR*2*ABC INSURANCE*****PI*12345~HL*2*1*21*1~NM1*41*2*XYZ SERVICE*****46*X67E~HL*3*2*19*1~NM1*1P*2*HOME HOSPITAL PHARMACY*****XX*1666666662~HL*4*3*PT~NM1*QC*1*SMITH*FRED****MI*123456789012~TRN*1*05347006051~STC*P2:80::RX*20070209**85~REF*XZ*7654321~DTP*472*D8*20070201~DTP*050*D8*20070206~SE*16*0001~GE*2*1~IEA*1*161130044~

Sample response (Claim Pending Status)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X228"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X228"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277PEND123",
            "BHT_04_Date_DT": "20070210",
            "BHT_05_Time_TM": "1635",
            "BHT_06_TransactionTypeCode_ID": "NO"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "PayerName_Loop_2100A": {
              "PayerName": {
                "NM1_01_EntityIdentifierCode_ID": "PR",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "PI",
                "NM1_09_IdentificationCode_AN": "12345",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            }
          },
          "InformationReceiverLevel_Loop_2000B": {
            "InformationReceiverLevel": {
              "HL_01_HierarchicalIDNumber_AN": "2",
              "HL_02_HierarchicalParentIDNumber_AN": "1",
              "HL_03_HierarchicalLevelCode_ID": "21",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationReceiverName_Loop_2100B": {
              "InformationReceiverName": {
                "NM1_01_EntityIdentifierCode_ID": "41",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "X67E",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            }
          },
          "ServiceProviderLevel_Loop_2000C": [
            {
              "ServiceProviderLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "19",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "ProviderName_Loop_2100C": [
                {
                  "ProviderName": {
                    "NM1_01_EntityIdentifierCode_ID": "1P",
                    "NM1_02_EntityTypeQualifier_ID": "2",
                    "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL PHARMACY",
                    "NM1_04_NameFirst_AN": null,
                    "NM1_05_NameMiddle_AN": null,
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "XX",
                    "NM1_09_IdentificationCode_AN": "1666666662",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  }
                }
              ]
            }
          ],
          "PatientLevel_Loop_2000D": [
            {
              "PatientLevel": {
                "HL_01_HierarchicalIDNumber_AN": "4",
                "HL_02_HierarchicalParentIDNumber_AN": "3",
                "HL_03_HierarchicalLevelCode_ID": "PT",
                "HL_04_HierarchicalChildCode_ID": null
              },
              "PatientName_Loop_2100D": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "FRED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "123456789012",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "PayerClaimControlNumber_Loop_2200D": [
                {
                  "PayerClaimControlNumber": {
                    "TRN_01_TraceTypeCode_ID": "1",
                    "TRN_02_ReferenceIdentification_AN": "05347006051",
                    "TRN_03_OriginatingCompanyIdentifier_AN": null,
                    "TRN_04_ReferenceIdentification_AN": null
                  },
                  "ClaimLevelStatusInformation": [
                    {
                      "STC_01_HealthClaimStatus": {
                        "C043_01_IndustryCode_AN": "P2",
                        "C043_02_IndustryCode_AN": "80",
                        "C043_03_EntityIdentifierCode_ID": null,
                        "C043_04_CodeListQualifierCode_ID": "RX"
                      },
                      "STC_02_Date_DT": "20070209",
                      "STC_03_ActionCode_ID": null,
                      "STC_04_MonetaryAmount_R": "85",
                      "STC_05_MonetaryAmount_R": null,
                      "STC_06_Date_DT": null,
                      "STC_07_PAymentMethodCode_ID": null,
                      "STC_08_Date_DT": null,
                      "STC_09_CheckNumber_AN": null,
                      "STC_10_HealthCareClaimStatus": null,
                      "STC_11_HealthCareClaimStatus": null,
                      "STC_12_FreeformMessageText_AN": null
                    }
                  ],
                  "PatientControlNumber": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "XZ",
                    "REF_02_ReferenceIdentification_AN": "7654321",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "InstitutionalBillTypeIdentification": null,
                  "PharmacyPrescriptionNumber": null,
                  "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                  "ClaimServiceDate": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20070201"
                  },
                  "ClaimReceivedDate": {
                    "DTP_01_DateTimeQualifier_ID": "050",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20070206"
                  },
                  "ServiceLineInformation_Loop_2220D": [
                    {
                      "ServiceLineInformation": null,
                      "ServiceLineStatusInformation": null,
                      "ServiceLineItemIdentification": null,
                      "PharmacyPrescriptionNumber": null,
                      "ServiceLineDate": null
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "16",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample request (Data Reporting Acknowledgment)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X364~ST*277*0003*005010X364~BHT*0085*08*0000221*20190221*1025~HL*1**20*1~NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~TRN*1*ABC12345~DTP*050*D8*20190220~DTP*009*D8*20190221~HL*2*1*21*1~NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~TRN*2*206438976580901~STC*DR02:20*20190221*WQ*365.5~QTY*90*3~QTY*AA*2~AMT*YU*200.5~AMT*YY*165~HL*3*2*19*1~NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~HL*4*3*PT~NM1*QC*1*PATIENT*FEMALE****MI*2222222222~TRN*2*PATIENT22222~STC*DR02:20:PR*20190221*WQ*100~REF*F8*IC847502~REF*1K*220216359803X~DTP*472*D8*20190214~HL*5*3*PT~NM1*QC*1*PATIENT*MALE****MI*3333333333~TRN*2*PATIENT33333~STC*DR06:21*20190221*U*65******DR06:255~REF*F8*IC429783~REF*1K*220216359954X~DTP*472*D8*20190121~HL*6*3*PT~NM1*QC*1*JONES*LARRY****MI*4444444444~TRN*2*JONES44444~STC*DR03:26:77*20190221*U*100~REF*F8*IC429805~REF*1K*220216359964X~DTP*472*D8*20190211~HL*7*2*19*1~NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~TRN*1*0~REF*LU*AB142~QTY*QA*2~AMT*YU*100.5~HL*8*7*PT~NM1*QC*1*JOHNSON*MARY****MI*5555555555~TRN*2*JOHNSON55555~STC*DR08:20:PR*20190221*EZ*50.5~REF*F8*IC429888~REF*1K*220216359806X~DTP*472*D8*20190210~SVC*HC:G9938*50.5*****1~STC*DR08:475**EZ~REF*6R*1~DTP*472*D8*20190210~HL*9*7*PT~NM1*QC*1*MILLS*HARRIETT****MI*6666666666~TRN*2*MILLS66666~STC*DR02:20:PR*20190221*WQ*50~REF*F8*IC429956~REF*1K*220216359807X~DTP*472*D8*20190205~SE*63*0003~GE*2*1~IEA*1*161130044~

Sample response (Data Reporting Acknowledgment)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X364"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0003",
            "ST_03_ImplementationConventionReference_AN": "005010X364"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "0000221",
            "BHT_04_Date_DT": "20190221",
            "BHT_05_Time_TM": "1025",
            "BHT_06_TransactionTypeCode_ID": null
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationSourceName_Loop_2100A": {
              "InformationSourceName": {
                "NM1_01_EntityIdentifierCode_ID": "ACV",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ALL PAYER CLAIMS DATABASE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "APCD01",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            },
            "TransmissionReceiptControlIdentifier_Loop_2200A": {
              "TransmissionReceiptControlIdentifier": {
                "TRN_01_TraceTypeCode_ID": "1",
                "TRN_02_ReferenceIdentification_AN": "ABC12345",
                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                "TRN_04_ReferenceIdentification_AN": null
              },
              "InformationSourceReceiptDate": {
                "DTP_01_DateTimeQualifier_ID": "050",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20190220"
              },
              "InformationSourceProcessDate": {
                "DTP_01_DateTimeQualifier_ID": "009",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20190221"
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "40",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "YOUR INSURANCE COMPANY",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "S00003",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "InformationReceiverApplicationTraceIdentifier_Loop_2200B": {
                "InformationReceiverApplicationTraceIdentifier": {
                  "TRN_01_TraceTypeCode_ID": "2",
                  "TRN_02_ReferenceIdentification_AN": "206438976580901",
                  "TRN_03_OriginatingCompanyIdentifier_AN": null,
                  "TRN_04_ReferenceIdentification_AN": null
                },
                "InformationReceiverStatusInformation": [
                  {
                    "STC_01_HealthClaimStatus": {
                      "C043_01_IndustryCode_AN": "DR02",
                      "C043_02_IndustryCode_AN": "20",
                      "C043_03_EntityIdentifierCode_ID": null,
                      "C043_04_CodeListQualifierCode_ID": null
                    },
                    "STC_02_Date_DT": "20190221",
                    "STC_03_ActionCode_ID": "WQ",
                    "STC_04_MonetaryAmount_R": "365.5",
                    "STC_05_MonetaryAmount_R": null,
                    "STC_06_Date_DT": null,
                    "STC_07_PAymentMethodCode_ID": null,
                    "STC_08_Date_DT": null,
                    "STC_09_CheckNumber_AN": null,
                    "STC_10_HealthCareClaimStatus": null,
                    "STC_11_HealthCareClaimStatus": null,
                    "STC_12_FreeformMessageText_AN": null
                  }
                ],
                "TotalAcceptedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "90",
                  "QTY_02_Quantity_R": "3",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalRejectedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "AA",
                  "QTY_02_Quantity_R": "2",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalAcceptedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YU",
                  "AMT_02_MonetaryAmount_R": "200.5",
                  "AMT_03_CreditDebitFlagCode_ID": null
                },
                "TotalRejectedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YY",
                  "AMT_02_MonetaryAmount_R": "165",
                  "AMT_03_CreditDebitFlagCode_ID": null
                }
              },
              "BillingServiceProviderHierarchicalLevel_Loop_2000C": [
                {
                  "BillingServiceProviderHierarchicalLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingServiceProviderName_Loop_2100C": {
                    "BillingServiceProviderName": {
                      "NM1_01_EntityIdentifierCode_ID": "85",
                      "NM1_02_EntityTypeQualifier_ID": "1",
                      "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                      "NM1_04_NameFirst_AN": "HARRY",
                      "NM1_05_NameMiddle_AN": "B",
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": "MD",
                      "NM1_08_IdentificationCodeQualifier_ID": "XX",
                      "NM1_09_IdentificationCode_AN": "1546326897",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "BillingServiceProviderTraceIdentifier_Loop_2200C": {
                    "BillingServiceProviderTraceIdentifier": null,
                    "BillingServiceProviderStatusInformation": null,
                    "BillingServiceProviderSecondaryIdentifier": null,
                    "TotalAcceptedQuantity": null,
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": null,
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "PATIENT",
                          "NM1_04_NameFirst_AN": "FEMALE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "2222222222",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "PATIENT22222",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR02",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "100",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC847502",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359803X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190214"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "5",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "PATIENT",
                          "NM1_04_NameFirst_AN": "MALE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "3333333333",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "PATIENT33333",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR06",
                                "C043_02_IndustryCode_AN": "21",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "65",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR06",
                                "C043_02_IndustryCode_AN": "255",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429783",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359954X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190121"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                          "NM1_04_NameFirst_AN": "LARRY",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "4444444444",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "JONES44444",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR03",
                                "C043_02_IndustryCode_AN": "26",
                                "C043_03_EntityIdentifierCode_ID": "77",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "100",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429805",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359964X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190211"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                },
                {
                  "BillingServiceProviderHierarchicalLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "7",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingServiceProviderName_Loop_2100C": {
                    "BillingServiceProviderName": {
                      "NM1_01_EntityIdentifierCode_ID": "85",
                      "NM1_02_EntityTypeQualifier_ID": "1",
                      "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                      "NM1_04_NameFirst_AN": "JOHN",
                      "NM1_05_NameMiddle_AN": "C",
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": "MD",
                      "NM1_08_IdentificationCodeQualifier_ID": "XX",
                      "NM1_09_IdentificationCode_AN": "1546326780",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "BillingServiceProviderTraceIdentifier_Loop_2200C": {
                    "BillingServiceProviderTraceIdentifier": {
                      "TRN_01_TraceTypeCode_ID": "1",
                      "TRN_02_ReferenceIdentification_AN": "0",
                      "TRN_03_OriginatingCompanyIdentifier_AN": null,
                      "TRN_04_ReferenceIdentification_AN": null
                    },
                    "BillingServiceProviderStatusInformation": null,
                    "BillingServiceProviderSecondaryIdentifier": [
                      {
                        "REF_01_ReferenceIdentificationQualifier_ID": "LU",
                        "REF_02_ReferenceIdentification_AN": "AB142",
                        "REF_03_Description_AN": null,
                        "REF_04_ReferenceIdentifier": null
                      }
                    ],
                    "TotalAcceptedQuantity": {
                      "QTY_01_QuantityQualifier_ID": "QA",
                      "QTY_02_Quantity_R": "2",
                      "QTY_03_CompositeUnitOfMeasure": null,
                      "QTY_04_FreeFormInformation_AN": null
                    },
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": {
                      "AMT_01_AmountQualifierCode_ID": "YU",
                      "AMT_02_MonetaryAmount_R": "100.5",
                      "AMT_03_CreditDebitFlagCode_ID": null
                    },
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "8",
                        "HL_02_HierarchicalParentIDNumber_AN": "7",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JOHNSON",
                          "NM1_04_NameFirst_AN": "MARY",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "5555555555",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "JOHNSON55555",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR08",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "EZ",
                              "STC_04_MonetaryAmount_R": "50.5",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429888",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359806X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190210"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": {
                                "SVC_01_CompositeMedicalProcedureIdentifier": {
                                  "C003_01_ProductServiceIDQualifier_ID": "HC",
                                  "C003_02_ProductServiceID_AN": "G9938",
                                  "C003_03_ProcedureModifier_AN": null,
                                  "C003_04_ProcedureModifier_AN": null,
                                  "C003_05_ProcedureModifier_AN": null,
                                  "C003_06_ProcedureModifier_AN": null,
                                  "C003_07_Description_AN": null,
                                  "C003_08_ProductServiceID_AN": null
                                },
                                "SVC_02_MonetaryAmount_R": "50.5",
                                "SVC_03_MonetaryAmount_R": null,
                                "SVC_04_ProductServiceId_AN": null,
                                "SVC_05_Quantity_R": null,
                                "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                "SVC_07_Quantity_R": "1"
                              },
                              "ServiceLineLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "DR08",
                                    "C043_02_IndustryCode_AN": "475",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": null,
                                  "STC_03_ActionCode_ID": "EZ",
                                  "STC_04_MonetaryAmount_R": null,
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "LineItemControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "6R",
                                "REF_02_ReferenceIdentification_AN": "1",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                                "DTP_03_DateTimePeriod_AN": "20190210"
                              }
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "9",
                        "HL_02_HierarchicalParentIDNumber_AN": "7",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "MILLS",
                          "NM1_04_NameFirst_AN": "HARRIETT",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "6666666666",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "MILLS66666",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR02",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "50",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429956",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359807X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190205"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "63",
            "SE_02_TransactionSetControlNumber_AN": "0003"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

JSON Request to EDI 277 Response

Transforms JSON into an EDI 277 message.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/json-to-edi277

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request (Claim Status)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X212"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X212"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0010",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277X212",
            "BHT_04_Date_DT": "20050916",
            "BHT_05_Time_TM": "0810",
            "BHT_06_TransactionTypeCode_ID": "DG"
          },
          "InformationSourceLevel_Loop_2000A": [
            {
              "InformationSourceLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "PayerName_Loop_2100A": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "12345",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerContactInformation": null
              },
              "InformationReceiverLevel_Loop_2000B": [
                {
                  "InformationReceiverLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "2",
                    "HL_02_HierarchicalParentIDNumber_AN": "1",
                    "HL_03_HierarchicalLevelCode_ID": "21",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "InformationReceiverName_Loop_2100B": {
                    "InformationReceiverName": {
                      "NM1_01_EntityIdentifierCode_ID": "41",
                      "NM1_02_EntityTypeQualifier_ID": "2",
                      "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICE",
                      "NM1_04_NameFirst_AN": null,
                      "NM1_05_NameMiddle_AN": null,
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": null,
                      "NM1_08_IdentificationCodeQualifier_ID": "46",
                      "NM1_09_IdentificationCode_AN": "X67E",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "InformationReceiverTraceIdentifier_Loop_2200B": {
                    "InformationReceiverTraceIdentifier": null,
                    "InformationReceiverStatusInformation": null
                  },
                  "ServiceProviderLevel_Loop_2000C": [
                    {
                      "ServiceProviderLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "3",
                        "HL_02_HierarchicalParentIDNumber_AN": "2",
                        "HL_03_HierarchicalLevelCode_ID": "19",
                        "HL_04_HierarchicalChildCode_ID": "1"
                      },
                      "ProviderName_Loop_2100C": [
                        {
                          "ProviderName": {
                            "NM1_01_EntityIdentifierCode_ID": "1P",
                            "NM1_02_EntityTypeQualifier_ID": "2",
                            "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL",
                            "NM1_04_NameFirst_AN": null,
                            "NM1_05_NameMiddle_AN": null,
                            "NM1_06_NamePrefix_AN": null,
                            "NM1_07_NameSuffix_AN": null,
                            "NM1_08_IdentificationCodeQualifier_ID": "XX",
                            "NM1_09_IdentificationCode_AN": "1666666661",
                            "NM1_10_EntityRelationshipCode_ID": null,
                            "NM1_11_EntityIdentifierCode_ID": null,
                            "NM1_12_NameLastOrOrganizationName_AN": null
                          }
                        }
                      ],
                      "ProviderOfServiceTraceIdentifier_Loop_2200C": {
                        "ProviderOfServiceTraceIdentifier": null,
                        "ProviderStatusInformation": null
                      },
                      "SubscriberLevel_Loop_2000D": [
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "4",
                            "HL_02_HierarchicalParentIDNumber_AN": "3",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "0"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                              "NM1_04_NameFirst_AN": "FRED",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "123456789A",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYZ1",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "P3",
                                    "C043_02_IndustryCode_AN": "317",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050913",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "8513.88",
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "05347006051",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                                "REF_02_ReferenceIdentification_AN": "111",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "SM123456",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                                "DTP_03_DateTimePeriod_AN": "20050831-20050906"
                              },
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        },
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "5",
                            "HL_02_HierarchicalParentIDNumber_AN": "3",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "0"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                              "NM1_04_NameFirst_AN": "MARY",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "234567890A",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYZ2",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "F0",
                                    "C043_02_IndustryCode_AN": "3",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050915",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "7599",
                                  "STC_05_MonetaryAmount_R": "7599",
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "0529675341",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                                "REF_02_ReferenceIdentification_AN": "111",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "JO234567",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                                "DTP_03_DateTimePeriod_AN": "20050731-20050809"
                              },
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ],
                      "DependentLevel_Loop_2000E": [
                        {
                          "DependentLevel": null,
                          "DependentName_Loop_2100E": {
                            "DependentName": null
                          },
                          "ClaimStatusTrackingNumber_Loop_2200E": [
                            {
                              "ClaimStatusTrackingNumber": null,
                              "ClaimLevelStatusInformation": null,
                              "PayerClaimControlNumber": null,
                              "InstitutionalBillTypeIdentification": null,
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220E": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "ServiceProviderLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "2",
                        "HL_03_HierarchicalLevelCode_ID": "19",
                        "HL_04_HierarchicalChildCode_ID": "1"
                      },
                      "ProviderName_Loop_2100C": [
                        {
                          "ProviderName": {
                            "NM1_01_EntityIdentifierCode_ID": "1P",
                            "NM1_02_EntityTypeQualifier_ID": "2",
                            "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL PHYSICIANS",
                            "NM1_04_NameFirst_AN": null,
                            "NM1_05_NameMiddle_AN": null,
                            "NM1_06_NamePrefix_AN": null,
                            "NM1_07_NameSuffix_AN": null,
                            "NM1_08_IdentificationCodeQualifier_ID": "XX",
                            "NM1_09_IdentificationCode_AN": "1666666666",
                            "NM1_10_EntityRelationshipCode_ID": null,
                            "NM1_11_EntityIdentifierCode_ID": null,
                            "NM1_12_NameLastOrOrganizationName_AN": null
                          }
                        }
                      ],
                      "ProviderOfServiceTraceIdentifier_Loop_2200C": {
                        "ProviderOfServiceTraceIdentifier": null,
                        "ProviderStatusInformation": null
                      },
                      "SubscriberLevel_Loop_2000D": [
                        {
                          "SubscriberLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "7",
                            "HL_02_HierarchicalParentIDNumber_AN": "6",
                            "HL_03_HierarchicalLevelCode_ID": "22",
                            "HL_04_HierarchicalChildCode_ID": "1"
                          },
                          "SubscriberName_Loop_2100D": {
                            "SubscriberName": {
                              "NM1_01_EntityIdentifierCode_ID": "IL",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "MANN",
                              "NM1_04_NameFirst_AN": "JOHN",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": "MI",
                              "NM1_09_IdentificationCode_AN": "345678901",
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200D": [
                            {
                              "ClaimStatusTrackingNumber": null,
                              "ClaimLevelStatusInformation": null,
                              "PayerClaimControlNumber": null,
                              "InstitutionalBillTypeIdentification": null,
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220D": [
                                {
                                  "ServiceLineInformation": null,
                                  "ServiceLineStatusInformation": null,
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": null
                                }
                              ]
                            }
                          ]
                        }
                      ],
                      "DependentLevel_Loop_2000E": [
                        {
                          "DependentLevel": {
                            "HL_01_HierarchicalIDNumber_AN": "8",
                            "HL_02_HierarchicalParentIDNumber_AN": "7",
                            "HL_03_HierarchicalLevelCode_ID": "23",
                            "HL_04_HierarchicalChildCode_ID": null
                          },
                          "DependentName_Loop_2100E": {
                            "DependentName": {
                              "NM1_01_EntityIdentifierCode_ID": "QC",
                              "NM1_02_EntityTypeQualifier_ID": "1",
                              "NM1_03_NameLastOrOrganizationName_AN": "MANN",
                              "NM1_04_NameFirst_AN": "JOSEPH",
                              "NM1_05_NameMiddle_AN": null,
                              "NM1_06_NamePrefix_AN": null,
                              "NM1_07_NameSuffix_AN": null,
                              "NM1_08_IdentificationCodeQualifier_ID": null,
                              "NM1_09_IdentificationCode_AN": null,
                              "NM1_10_EntityRelationshipCode_ID": null,
                              "NM1_11_EntityIdentifierCode_ID": null,
                              "NM1_12_NameLastOrOrganizationName_AN": null
                            }
                          },
                          "ClaimStatusTrackingNumber_Loop_2200E": [
                            {
                              "ClaimStatusTrackingNumber": {
                                "TRN_01_TraceTypeCode_ID": "2",
                                "TRN_02_ReferenceIdentification_AN": "ABCXYC3",
                                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                                "TRN_04_ReferenceIdentification_AN": null
                              },
                              "ClaimLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "F2",
                                    "C043_02_IndustryCode_AN": "88",
                                    "C043_03_EntityIdentifierCode_ID": "QC",
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": "20050612",
                                  "STC_03_ActionCode_ID": null,
                                  "STC_04_MonetaryAmount_R": "150",
                                  "STC_05_MonetaryAmount_R": "0",
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "PayerClaimControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                                "REF_02_ReferenceIdentification_AN": "051681010827",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "InstitutionalBillTypeIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                                "REF_02_ReferenceIdentification_AN": "MA345678",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PatientControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "VoucherIdentifier": null,
                              "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                              "ClaimServiceDate": null,
                              "ServiceLineInformation_Loop_2220E": [
                                {
                                  "ServiceLineInformation": {
                                    "SVC_01_CompositeMedicalProcedureIdentifier": {
                                      "C003_01_ProductServiceIDQualifier_ID": "HC",
                                      "C003_02_ProductServiceID_AN": "99203",
                                      "C003_03_ProcedureModifier_AN": null,
                                      "C003_04_ProcedureModifier_AN": null,
                                      "C003_05_ProcedureModifier_AN": null,
                                      "C003_06_ProcedureModifier_AN": null,
                                      "C003_07_Description_AN": null,
                                      "C003_08_ProductServiceID_AN": null
                                    },
                                    "SVC_02_MonetaryAmount_R": "150",
                                    "SVC_03_MonetaryAmount_R": "0",
                                    "SVC_04_ProductServiceId_AN": null,
                                    "SVC_05_Quantity_R": null,
                                    "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                    "SVC_07_Quantity_R": "1"
                                  },
                                  "ServiceLineStatusInformation": [
                                    {
                                      "STC_01_HealthClaimStatus": {
                                        "C043_01_IndustryCode_AN": "F2",
                                        "C043_02_IndustryCode_AN": "88",
                                        "C043_03_EntityIdentifierCode_ID": "QC",
                                        "C043_04_CodeListQualifierCode_ID": null
                                      },
                                      "STC_02_Date_DT": "20050612",
                                      "STC_03_ActionCode_ID": null,
                                      "STC_04_MonetaryAmount_R": null,
                                      "STC_05_MonetaryAmount_R": null,
                                      "STC_06_Date_DT": null,
                                      "STC_07_PAymentMethodCode_ID": null,
                                      "STC_08_Date_DT": null,
                                      "STC_09_CheckNumber_AN": null,
                                      "STC_10_HealthCareClaimStatus": null,
                                      "STC_11_HealthCareClaimStatus": null,
                                      "STC_12_FreeformMessageText_AN": null
                                    }
                                  ],
                                  "ServiceLineItemIdentification": null,
                                  "ServiceLineDate": {
                                    "DTP_01_DateTimeQualifier_ID": "472",
                                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                                    "DTP_03_DateTimePeriod_AN": "20050501"
                                  }
                                }
                              ]
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "38",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample response (Claim Status)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X212~ST*277*0001*005010X212~BHT*0010*08*277X212*20050916*0810*DG~HL*1**20*1~NM1*PR*2*ABC INSURANCE*****PI*12345~HL*2*1*21*1~NM1*41*2*XYZ SERVICE*****46*X67E~HL*3*2*19*1~NM1*1P*2*HOME HOSPITAL*****XX*1666666661~HL*4*3*22*0~NM1*IL*1*SMITH*FRED****MI*123456789A~TRN*2*ABCXYZ1~STC*P3:317*20050913**8513.88~REF*1K*05347006051~REF*BLT*111~REF*EJ*SM123456~DTP*472*RD8*20050831-20050906~HL*5*3*22*0~NM1*IL*1*JONES*MARY****MI*234567890A~TRN*2*ABCXYZ2~STC*F0:3*20050915**7599*7599~REF*1K*0529675341~REF*BLT*111~REF*EJ*JO234567~DTP*472*RD8*20050731-20050809~HL*6*2*19*1~NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666666~HL*7*6*22*1~NM1*IL*1*MANN*JOHN****MI*345678901~HL*8*7*23~NM1*QC*1*MANN*JOSEPH~TRN*2*ABCXYC3~STC*F2:88:QC*20050612**150*0~REF*1K*051681010827~REF*EJ*MA345678~SVC*HC:99203*150*0****1~STC*F2:88:QC*20050612~DTP*472*D8*20050501~SE*38*0001~GE*2*1~IEA*1*161130044~

Sample request (Claim Status with Additional Information)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X213"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "1001",
            "ST_03_ImplementationConventionReference_AN": "005010X213"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "48",
            "BHT_03_ReferenceIdentification_AN": "277X213000001",
            "BHT_04_Date_DT": "20060824",
            "BHT_05_Time_TM": "1211",
            "BHT_06_TransactionTypeCode_ID": "RQ"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "PayerName_Loop_2100A": {
              "PayerName": {
                "NM1_01_EntityIdentifierCode_ID": "PR",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE COMPANY",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "XV",
                "NM1_09_IdentificationCode_AN": "12345",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              },
              "PayerContactInformation": {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "MEDICAL REVIEW DEPARTMENT",
                "PER_03_CommunicationNumberQualifier_ID": "FX",
                "PER_04_CommunicationNumber_AN": "7771114321",
                "PER_05_CommunicationNumberQualifier_ID": "TE",
                "PER_06_CommunicationNumber_AN": "5555555555",
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "41",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "A222222221",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "ServiceProviderLevel_Loop_2000C": [
                {
                  "ServiceProviderLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "ServiceProviderName_Loop_2100C": [
                    {
                      "ProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "1P",
                        "NM1_02_EntityTypeQualifier_ID": "2",
                        "NM1_03_NameLastOrOrganizationName_AN": "ST HOLY HILLS HOSPITAL",
                        "NM1_04_NameFirst_AN": null,
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "1666666666",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      }
                    }
                  ],
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JACKSON",
                          "NM1_04_NameFirst_AN": "JACK",
                          "NM1_05_NameMiddle_AN": "J",
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "987654320",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "PayerClaimControlNumber_Loop_2200D": [
                        {
                          "PayerClaimControlNumber": {
                            "TRN_01_TraceTypeCode_ID": "1",
                            "TRN_02_ReferenceIdentification_AN": "1822634840",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "R4",
                                "C043_02_IndustryCode_AN": "18594-2",
                                "C043_03_EntityIdentifierCode_ID": "20060824",
                                "C043_04_CodeListQualifierCode_ID": "LOI"
                              },
                              "STC_02_Date_DT": "20060824",
                              "STC_03_ActionCode_ID": null,
                              "STC_04_MonetaryAmount_R": null,
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PatientControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "BLT",
                            "REF_02_ReferenceIdentification_AN": "111",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "InstitutionalTypeOfBill": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "EJ",
                            "REF_02_ReferenceIdentification_AN": "JACKSON123",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "MedicalRecordIdentificationNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "EA",
                            "REF_02_ReferenceIdentification_AN": "STHHL12345",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "ClaimServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060812"
                          },
                          "ResponseDueDate": {
                            "DTP_01_DateTimeQualifier_ID": "106",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060923"
                          },
                          "ClaimSupplementalInformation_Loop_2210D": {
                            "ClaimSupplementalInformation": null,
                            "PayerResponseContactInformation": null,
                            "PayerResponseContactAddress": null,
                            "PayerResponseContactCityStateZipCode": null
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "19",
            "SE_02_TransactionSetControlNumber_AN": "1001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample response (Claim Status with Additional Information)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X213~ST*277*1001*005010X213~BHT*0085*48*277X213000001*20060824*1211*RQ~HL*1**20*1~NM1*PR*2*ABC INSURANCE COMPANY*****XV*12345~PER*IC*MEDICAL REVIEW DEPARTMENT*FX*7771114321*TE*5555555555~HL*2*1*21*1~NM1*41*2*XYZ SERVICES*****46*A222222221~HL*3*2*19*1~NM1*1P*2*ST HOLY HILLS HOSPITAL*****XX*1666666666~HL*4*3*PT~NM1*QC*1*JACKSON*JACK*J***MI*987654320~TRN*1*1822634840~STC*R4:18594-2:20060824:LOI*20060824~REF*BLT*111~REF*EJ*JACKSON123~REF*EA*STHHL12345~DTP*472*D8*20060812~DTP*106*D8*20060923~SE*19*1001~GE*2*1~IEA*1*161130044~

Sample request (Claim Acknowledgment)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X214"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X214"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277X2140001",
            "BHT_04_Date_DT": "20060205",
            "BHT_05_Time_TM": "1635",
            "BHT_06_TransactionTypeCode_ID": "TH"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationSourceName_Loop_2100A": {
              "InformationSourceName": {
                "NM1_01_EntityIdentifierCode_ID": "AY",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "FIRST CLEARINGHOUSE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "CLHR00",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            },
            "TransmissionReceiptControlIdentifier_Loop_2200A": {
              "TransmissionReceiptControlIdentifier": {
                "TRN_01_TraceTypeCode_ID": "1",
                "TRN_02_ReferenceIdentification_AN": "200102051635S00001ABCDEF",
                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                "TRN_04_ReferenceIdentification_AN": null
              },
              "InformationSourceReceiptDate": {
                "DTP_01_DateTimeQualifier_ID": "050",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20060205"
              },
              "InformationSourceProcessDate": {
                "DTP_01_DateTimeQualifier_ID": "009",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20060205"
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "41",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "BEST BILLING SERVICE",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "S00001",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "InformationReceiverApplicationTraceIdentifier_Loop_2200B": {
                "InformationReceiverApplicationTraceIdentifier": {
                  "TRN_01_TraceTypeCode_ID": "2",
                  "TRN_02_ReferenceIdentification_AN": "2002020542857",
                  "TRN_03_OriginatingCompanyIdentifier_AN": null,
                  "TRN_04_ReferenceIdentification_AN": null
                },
                "InformationReceiverStatusInformation": [
                  {
                    "STC_01_HealthClaimStatus": {
                      "C043_01_IndustryCode_AN": "A0",
                      "C043_02_IndustryCode_AN": "16",
                      "C043_03_EntityIdentifierCode_ID": "PR",
                      "C043_04_CodeListQualifierCode_ID": null
                    },
                    "STC_02_Date_DT": "20060205",
                    "STC_03_ActionCode_ID": "WQ",
                    "STC_04_MonetaryAmount_R": "1000",
                    "STC_05_MonetaryAmount_R": null,
                    "STC_06_Date_DT": null,
                    "STC_07_PAymentMethodCode_ID": null,
                    "STC_08_Date_DT": null,
                    "STC_09_CheckNumber_AN": null,
                    "STC_10_HealthCareClaimStatus": null,
                    "STC_11_HealthCareClaimStatus": null,
                    "STC_12_FreeformMessageText_AN": null
                  }
                ],
                "TotalAcceptedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "90",
                  "QTY_02_Quantity_R": "1",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalRejectedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "AA",
                  "QTY_02_Quantity_R": "2",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalAcceptedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YU",
                  "AMT_02_MonetaryAmount_R": "200",
                  "AMT_03_CreditDebitFlagCode_ID": null
                },
                "TotalRejectedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YY",
                  "AMT_02_MonetaryAmount_R": "800",
                  "AMT_03_CreditDebitFlagCode_ID": null
                }
              },
              "BillingProviderOfServiceLevel_Loop_2000C": [
                {
                  "BillingProviderOfServiceLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingProviderName_Loop_2100C": [
                    {
                      "BillingProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "85",
                        "NM1_02_EntityTypeQualifier_ID": "2",
                        "NM1_03_NameLastOrOrganizationName_AN": "SMITH CLINIC",
                        "NM1_04_NameFirst_AN": null,
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "FI",
                        "NM1_09_IdentificationCode_AN": "123456789",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      }
                    }
                  ],
                  "ProviderOfServiceInformationTraceIdentifier_Loop_2200C": {
                    "ProviderOfServiceInformationTraceIdentifier": null,
                    "BillingProviderStatusInformation": null,
                    "ProviderSecondaryIdentifier": null,
                    "TotalAcceptedQuantity": null,
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": null,
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                          "NM1_04_NameFirst_AN": "JOHN",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "00ABCD1234",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "DOE01428",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A0",
                                "C043_02_IndustryCode_AN": "16",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "200",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "22029500123407X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                            "DTP_03_DateTimePeriod_AN": "20060128-20060131"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "5",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                          "NM1_04_NameFirst_AN": "JANE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "45613027602",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "DOE0221",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A3",
                                "C043_02_IndustryCode_AN": "21",
                                "C043_03_EntityIdentifierCode_ID": "82",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "500",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": null,
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20060115"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": {
                                "SVC_01_CompositeMedicalProcedureIdentifier": {
                                  "C003_01_ProductServiceIDQualifier_ID": "HC",
                                  "C003_02_ProductServiceID_AN": "22305",
                                  "C003_03_ProcedureModifier_AN": "22",
                                  "C003_04_ProcedureModifier_AN": null,
                                  "C003_05_ProcedureModifier_AN": null,
                                  "C003_06_ProcedureModifier_AN": null,
                                  "C003_07_Description_AN": null,
                                  "C003_08_ProductServiceID_AN": null
                                },
                                "SVC_02_MonetaryAmount_R": "350",
                                "SVC_03_MonetaryAmount_R": null,
                                "SVC_04_ProductServiceId_AN": null,
                                "SVC_05_Quantity_R": null,
                                "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                "SVC_07_Quantity_R": "1"
                              },
                              "ServiceLineLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "A3",
                                    "C043_02_IndustryCode_AN": "122",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": null,
                                  "STC_03_ActionCode_ID": "U",
                                  "STC_04_MonetaryAmount_R": null,
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": {
                                    "C043_01_IndustryCode_AN": "A3",
                                    "C043_02_IndustryCode_AN": "153",
                                    "C043_03_EntityIdentifierCode_ID": "82",
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "ServiceLineItemIdentification": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "FJ",
                                "REF_02_ReferenceIdentification_AN": "11",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "VEST",
                          "NM1_04_NameFirst_AN": "HELEN",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "45602708901",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "VEST0303",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "A3",
                                "C043_02_IndustryCode_AN": "401",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20060205",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "300",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "PayerClaimControlNumber": null,
                          "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                          "InstitutionalBillTypeIdentification": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "RD8",
                            "DTP_03_DateTimePeriod_AN": "20060120-20060120"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "ServiceLineItemIdentification": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "37",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": null
    }
  ],
  "InterchangeControlTrailerSegment": null
}

Sample response (Claim Acknowledgment)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X214~ST*277*0001*005010X214~BHT*0085*08*277X2140001*20060205*1635*TH~HL*1**20*1~NM1*AY*2*FIRST CLEARINGHOUSE*****46*CLHR00~TRN*1*200102051635S00001ABCDEF~DTP*050*D8*20060205~DTP*009*D8*20060205~HL*2*1*21*1~NM1*41*2*BEST BILLING SERVICE*****46*S00001~TRN*2*2002020542857~STC*A0:16:PR*20060205*WQ*1000~QTY*90*1~QTY*AA*2~AMT*YU*200~AMT*YY*800~HL*3*2*19*1~NM1*85*2*SMITH CLINIC*****FI*123456789~HL*4*3*PT~NM1*QC*1*DOE*JOHN****MI*00ABCD1234~TRN*2*DOE01428~STC*A0:16:PR*20060205*WQ*200~REF*1K*22029500123407X~DTP*472*RD8*20060128-20060131~HL*5*3*PT~NM1*QC*1*DOE*JANE****MI*45613027602~TRN*2*DOE0221~STC*A3:21:82*20060205*U*500~DTP*472*D8*20060115~SVC*HC:22305:22*350*****1~STC*A3:122**U*******A3:153:82~REF*FJ*11~HL*6*3*PT~NM1*QC*1*VEST*HELEN****MI*45602708901~TRN*2*VEST0303~STC*A3:401*20060205*U*300~DTP*472*RD8*20060120-20060120~SE*37*0001~SE*9*0001~GE*2*1~IEA*1*161130044~

Sample request (Claim Pending Status)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X228"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0001",
            "ST_03_ImplementationConventionReference_AN": "005010X228"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "277PEND123",
            "BHT_04_Date_DT": "20070210",
            "BHT_05_Time_TM": "1635",
            "BHT_06_TransactionTypeCode_ID": "NO"
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "PayerName_Loop_2100A": {
              "PayerName": {
                "NM1_01_EntityIdentifierCode_ID": "PR",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ABC INSURANCE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "PI",
                "NM1_09_IdentificationCode_AN": "12345",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            }
          },
          "InformationReceiverLevel_Loop_2000B": {
            "InformationReceiverLevel": {
              "HL_01_HierarchicalIDNumber_AN": "2",
              "HL_02_HierarchicalParentIDNumber_AN": "1",
              "HL_03_HierarchicalLevelCode_ID": "21",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationReceiverName_Loop_2100B": {
              "InformationReceiverName": {
                "NM1_01_EntityIdentifierCode_ID": "41",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "XYZ SERVICE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "X67E",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            }
          },
          "ServiceProviderLevel_Loop_2000C": [
            {
              "ServiceProviderLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "19",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "ProviderName_Loop_2100C": [
                {
                  "ProviderName": {
                    "NM1_01_EntityIdentifierCode_ID": "1P",
                    "NM1_02_EntityTypeQualifier_ID": "2",
                    "NM1_03_NameLastOrOrganizationName_AN": "HOME HOSPITAL PHARMACY",
                    "NM1_04_NameFirst_AN": null,
                    "NM1_05_NameMiddle_AN": null,
                    "NM1_06_NamePrefix_AN": null,
                    "NM1_07_NameSuffix_AN": null,
                    "NM1_08_IdentificationCodeQualifier_ID": "XX",
                    "NM1_09_IdentificationCode_AN": "1666666662",
                    "NM1_10_EntityRelationshipCode_ID": null,
                    "NM1_11_EntityIdentifierCode_ID": null,
                    "NM1_12_NameLastOrOrganizationName_AN": null
                  }
                }
              ]
            }
          ],
          "PatientLevel_Loop_2000D": [
            {
              "PatientLevel": {
                "HL_01_HierarchicalIDNumber_AN": "4",
                "HL_02_HierarchicalParentIDNumber_AN": "3",
                "HL_03_HierarchicalLevelCode_ID": "PT",
                "HL_04_HierarchicalChildCode_ID": null
              },
              "PatientName_Loop_2100D": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "FRED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "123456789012",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "PayerClaimControlNumber_Loop_2200D": [
                {
                  "PayerClaimControlNumber": {
                    "TRN_01_TraceTypeCode_ID": "1",
                    "TRN_02_ReferenceIdentification_AN": "05347006051",
                    "TRN_03_OriginatingCompanyIdentifier_AN": null,
                    "TRN_04_ReferenceIdentification_AN": null
                  },
                  "ClaimLevelStatusInformation": [
                    {
                      "STC_01_HealthClaimStatus": {
                        "C043_01_IndustryCode_AN": "P2",
                        "C043_02_IndustryCode_AN": "80",
                        "C043_03_EntityIdentifierCode_ID": null,
                        "C043_04_CodeListQualifierCode_ID": "RX"
                      },
                      "STC_02_Date_DT": "20070209",
                      "STC_03_ActionCode_ID": null,
                      "STC_04_MonetaryAmount_R": "85",
                      "STC_05_MonetaryAmount_R": null,
                      "STC_06_Date_DT": null,
                      "STC_07_PAymentMethodCode_ID": null,
                      "STC_08_Date_DT": null,
                      "STC_09_CheckNumber_AN": null,
                      "STC_10_HealthCareClaimStatus": null,
                      "STC_11_HealthCareClaimStatus": null,
                      "STC_12_FreeformMessageText_AN": null
                    }
                  ],
                  "PatientControlNumber": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "XZ",
                    "REF_02_ReferenceIdentification_AN": "7654321",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "InstitutionalBillTypeIdentification": null,
                  "PharmacyPrescriptionNumber": null,
                  "ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries": null,
                  "ClaimServiceDate": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20070201"
                  },
                  "ClaimReceivedDate": {
                    "DTP_01_DateTimeQualifier_ID": "050",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20070206"
                  },
                  "ServiceLineInformation_Loop_2220D": [
                    {
                      "ServiceLineInformation": null,
                      "ServiceLineStatusInformation": null,
                      "ServiceLineItemIdentification": null,
                      "PharmacyPrescriptionNumber": null,
                      "ServiceLineDate": null
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "16",
            "SE_02_TransactionSetControlNumber_AN": "0001"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample response (Claim Pending Status)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X228~ST*277*0001*005010X228~BHT*0085*08*277PEND123*20070210*1635*NO~HL*1**20*1~NM1*PR*2*ABC INSURANCE*****PI*12345~HL*2*1*21*1~NM1*41*2*XYZ SERVICE*****46*X67E~HL*3*2*19*1~NM1*1P*2*HOME HOSPITAL PHARMACY*****XX*1666666662~HL*4*3*PT~NM1*QC*1*SMITH*FRED****MI*123456789012~TRN*1*05347006051~STC*P2:80::RX*20070209**85~REF*XZ*7654321~DTP*472*D8*20070201~DTP*050*D8*20070206~SE*16*0001~GE*2*1~IEA*1*161130044~

Sample request (Data Reporting Acknowledgment)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SENDER         ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVER       ",
    "ISA_09_InterchangeDate_DT": "220610",
    "ISA_10_InterchangeTime_TM": "1300",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "161130044",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "HB",
        "GS_02_ApplicationSendersCode_AN": "SENDER",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVER",
        "GS_04_Date_DT": "20220610",
        "GS_05_Time_TM": "1300",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X364"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "277",
            "ST_02_TransactionSetControlNumber_AN": "0003",
            "ST_03_ImplementationConventionReference_AN": "005010X364"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0085",
            "BHT_02_TransactionSetPurposeCode_ID": "08",
            "BHT_03_ReferenceIdentification_AN": "0000221",
            "BHT_04_Date_DT": "20190221",
            "BHT_05_Time_TM": "1025",
            "BHT_06_TransactionTypeCode_ID": null
          },
          "InformationSourceLevel_Loop_2000A": {
            "InformationSourceLevel": {
              "HL_01_HierarchicalIDNumber_AN": "1",
              "HL_02_HierarchicalParentIDNumber_AN": null,
              "HL_03_HierarchicalLevelCode_ID": "20",
              "HL_04_HierarchicalChildCode_ID": "1"
            },
            "InformationSourceName_Loop_2100A": {
              "InformationSourceName": {
                "NM1_01_EntityIdentifierCode_ID": "ACV",
                "NM1_02_EntityTypeQualifier_ID": "2",
                "NM1_03_NameLastOrOrganizationName_AN": "ALL PAYER CLAIMS DATABASE",
                "NM1_04_NameFirst_AN": null,
                "NM1_05_NameMiddle_AN": null,
                "NM1_06_NamePrefix_AN": null,
                "NM1_07_NameSuffix_AN": null,
                "NM1_08_IdentificationCodeQualifier_ID": "46",
                "NM1_09_IdentificationCode_AN": "APCD01",
                "NM1_10_EntityRelationshipCode_ID": null,
                "NM1_11_EntityIdentifierCode_ID": null,
                "NM1_12_NameLastOrOrganizationName_AN": null
              }
            },
            "TransmissionReceiptControlIdentifier_Loop_2200A": {
              "TransmissionReceiptControlIdentifier": {
                "TRN_01_TraceTypeCode_ID": "1",
                "TRN_02_ReferenceIdentification_AN": "ABC12345",
                "TRN_03_OriginatingCompanyIdentifier_AN": null,
                "TRN_04_ReferenceIdentification_AN": null
              },
              "InformationSourceReceiptDate": {
                "DTP_01_DateTimeQualifier_ID": "050",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20190220"
              },
              "InformationSourceProcessDate": {
                "DTP_01_DateTimeQualifier_ID": "009",
                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                "DTP_03_DateTimePeriod_AN": "20190221"
              }
            },
            "InformationReceiverLevel_Loop_2000B": {
              "InformationReceiverLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "21",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "InformationReceiverName_Loop_2100B": {
                "InformationReceiverName": {
                  "NM1_01_EntityIdentifierCode_ID": "40",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "YOUR INSURANCE COMPANY",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "46",
                  "NM1_09_IdentificationCode_AN": "S00003",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                }
              },
              "InformationReceiverApplicationTraceIdentifier_Loop_2200B": {
                "InformationReceiverApplicationTraceIdentifier": {
                  "TRN_01_TraceTypeCode_ID": "2",
                  "TRN_02_ReferenceIdentification_AN": "206438976580901",
                  "TRN_03_OriginatingCompanyIdentifier_AN": null,
                  "TRN_04_ReferenceIdentification_AN": null
                },
                "InformationReceiverStatusInformation": [
                  {
                    "STC_01_HealthClaimStatus": {
                      "C043_01_IndustryCode_AN": "DR02",
                      "C043_02_IndustryCode_AN": "20",
                      "C043_03_EntityIdentifierCode_ID": null,
                      "C043_04_CodeListQualifierCode_ID": null
                    },
                    "STC_02_Date_DT": "20190221",
                    "STC_03_ActionCode_ID": "WQ",
                    "STC_04_MonetaryAmount_R": "365.5",
                    "STC_05_MonetaryAmount_R": null,
                    "STC_06_Date_DT": null,
                    "STC_07_PAymentMethodCode_ID": null,
                    "STC_08_Date_DT": null,
                    "STC_09_CheckNumber_AN": null,
                    "STC_10_HealthCareClaimStatus": null,
                    "STC_11_HealthCareClaimStatus": null,
                    "STC_12_FreeformMessageText_AN": null
                  }
                ],
                "TotalAcceptedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "90",
                  "QTY_02_Quantity_R": "3",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalRejectedQuantity": {
                  "QTY_01_QuantityQualifier_ID": "AA",
                  "QTY_02_Quantity_R": "2",
                  "QTY_03_CompositeUnitOfMeasure": null,
                  "QTY_04_FreeFormInformation_AN": null
                },
                "TotalAcceptedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YU",
                  "AMT_02_MonetaryAmount_R": "200.5",
                  "AMT_03_CreditDebitFlagCode_ID": null
                },
                "TotalRejectedAmount": {
                  "AMT_01_AmountQualifierCode_ID": "YY",
                  "AMT_02_MonetaryAmount_R": "165",
                  "AMT_03_CreditDebitFlagCode_ID": null
                }
              },
              "BillingServiceProviderHierarchicalLevel_Loop_2000C": [
                {
                  "BillingServiceProviderHierarchicalLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "3",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingServiceProviderName_Loop_2100C": {
                    "BillingServiceProviderName": {
                      "NM1_01_EntityIdentifierCode_ID": "85",
                      "NM1_02_EntityTypeQualifier_ID": "1",
                      "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                      "NM1_04_NameFirst_AN": "HARRY",
                      "NM1_05_NameMiddle_AN": "B",
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": "MD",
                      "NM1_08_IdentificationCodeQualifier_ID": "XX",
                      "NM1_09_IdentificationCode_AN": "1546326897",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "BillingServiceProviderTraceIdentifier_Loop_2200C": {
                    "BillingServiceProviderTraceIdentifier": null,
                    "BillingServiceProviderStatusInformation": null,
                    "BillingServiceProviderSecondaryIdentifier": null,
                    "TotalAcceptedQuantity": null,
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": null,
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "4",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "PATIENT",
                          "NM1_04_NameFirst_AN": "FEMALE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "2222222222",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "PATIENT22222",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR02",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "100",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC847502",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359803X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190214"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "5",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "PATIENT",
                          "NM1_04_NameFirst_AN": "MALE",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "3333333333",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "PATIENT33333",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR06",
                                "C043_02_IndustryCode_AN": "21",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "65",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR06",
                                "C043_02_IndustryCode_AN": "255",
                                "C043_03_EntityIdentifierCode_ID": null,
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429783",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359954X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190121"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "6",
                        "HL_02_HierarchicalParentIDNumber_AN": "3",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                          "NM1_04_NameFirst_AN": "LARRY",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "4444444444",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "JONES44444",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR03",
                                "C043_02_IndustryCode_AN": "26",
                                "C043_03_EntityIdentifierCode_ID": "77",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "U",
                              "STC_04_MonetaryAmount_R": "100",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429805",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359964X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190211"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                },
                {
                  "BillingServiceProviderHierarchicalLevel": {
                    "HL_01_HierarchicalIDNumber_AN": "7",
                    "HL_02_HierarchicalParentIDNumber_AN": "2",
                    "HL_03_HierarchicalLevelCode_ID": "19",
                    "HL_04_HierarchicalChildCode_ID": "1"
                  },
                  "BillingServiceProviderName_Loop_2100C": {
                    "BillingServiceProviderName": {
                      "NM1_01_EntityIdentifierCode_ID": "85",
                      "NM1_02_EntityTypeQualifier_ID": "1",
                      "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                      "NM1_04_NameFirst_AN": "JOHN",
                      "NM1_05_NameMiddle_AN": "C",
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": "MD",
                      "NM1_08_IdentificationCodeQualifier_ID": "XX",
                      "NM1_09_IdentificationCode_AN": "1546326780",
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    }
                  },
                  "BillingServiceProviderTraceIdentifier_Loop_2200C": {
                    "BillingServiceProviderTraceIdentifier": {
                      "TRN_01_TraceTypeCode_ID": "1",
                      "TRN_02_ReferenceIdentification_AN": "0",
                      "TRN_03_OriginatingCompanyIdentifier_AN": null,
                      "TRN_04_ReferenceIdentification_AN": null
                    },
                    "BillingServiceProviderStatusInformation": null,
                    "BillingServiceProviderSecondaryIdentifier": [
                      {
                        "REF_01_ReferenceIdentificationQualifier_ID": "LU",
                        "REF_02_ReferenceIdentification_AN": "AB142",
                        "REF_03_Description_AN": null,
                        "REF_04_ReferenceIdentifier": null
                      }
                    ],
                    "TotalAcceptedQuantity": {
                      "QTY_01_QuantityQualifier_ID": "QA",
                      "QTY_02_Quantity_R": "2",
                      "QTY_03_CompositeUnitOfMeasure": null,
                      "QTY_04_FreeFormInformation_AN": null
                    },
                    "TotalRejectedQuantity": null,
                    "TotalAcceptedAmount": {
                      "AMT_01_AmountQualifierCode_ID": "YU",
                      "AMT_02_MonetaryAmount_R": "100.5",
                      "AMT_03_CreditDebitFlagCode_ID": null
                    },
                    "TotalRejectedAmount": null
                  },
                  "PatientLevel_Loop_2000D": [
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "8",
                        "HL_02_HierarchicalParentIDNumber_AN": "7",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "JOHNSON",
                          "NM1_04_NameFirst_AN": "MARY",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "5555555555",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "JOHNSON55555",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR08",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "EZ",
                              "STC_04_MonetaryAmount_R": "50.5",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429888",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359806X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190210"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": {
                                "SVC_01_CompositeMedicalProcedureIdentifier": {
                                  "C003_01_ProductServiceIDQualifier_ID": "HC",
                                  "C003_02_ProductServiceID_AN": "G9938",
                                  "C003_03_ProcedureModifier_AN": null,
                                  "C003_04_ProcedureModifier_AN": null,
                                  "C003_05_ProcedureModifier_AN": null,
                                  "C003_06_ProcedureModifier_AN": null,
                                  "C003_07_Description_AN": null,
                                  "C003_08_ProductServiceID_AN": null
                                },
                                "SVC_02_MonetaryAmount_R": "50.5",
                                "SVC_03_MonetaryAmount_R": null,
                                "SVC_04_ProductServiceId_AN": null,
                                "SVC_05_Quantity_R": null,
                                "SVC_06_CompositeMedicalProcedureIdentifier": null,
                                "SVC_07_Quantity_R": "1"
                              },
                              "ServiceLineLevelStatusInformation": [
                                {
                                  "STC_01_HealthClaimStatus": {
                                    "C043_01_IndustryCode_AN": "DR08",
                                    "C043_02_IndustryCode_AN": "475",
                                    "C043_03_EntityIdentifierCode_ID": null,
                                    "C043_04_CodeListQualifierCode_ID": null
                                  },
                                  "STC_02_Date_DT": null,
                                  "STC_03_ActionCode_ID": "EZ",
                                  "STC_04_MonetaryAmount_R": null,
                                  "STC_05_MonetaryAmount_R": null,
                                  "STC_06_Date_DT": null,
                                  "STC_07_PAymentMethodCode_ID": null,
                                  "STC_08_Date_DT": null,
                                  "STC_09_CheckNumber_AN": null,
                                  "STC_10_HealthCareClaimStatus": null,
                                  "STC_11_HealthCareClaimStatus": null,
                                  "STC_12_FreeformMessageText_AN": null
                                }
                              ],
                              "LineItemControlNumber": {
                                "REF_01_ReferenceIdentificationQualifier_ID": "6R",
                                "REF_02_ReferenceIdentification_AN": "1",
                                "REF_03_Description_AN": null,
                                "REF_04_ReferenceIdentifier": null
                              },
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": {
                                "DTP_01_DateTimeQualifier_ID": "472",
                                "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                                "DTP_03_DateTimePeriod_AN": "20190210"
                              }
                            }
                          ]
                        }
                      ]
                    },
                    {
                      "PatientLevel": {
                        "HL_01_HierarchicalIDNumber_AN": "9",
                        "HL_02_HierarchicalParentIDNumber_AN": "7",
                        "HL_03_HierarchicalLevelCode_ID": "PT",
                        "HL_04_HierarchicalChildCode_ID": null
                      },
                      "PatientName_Loop_2100D": {
                        "PatientName": {
                          "NM1_01_EntityIdentifierCode_ID": "QC",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "MILLS",
                          "NM1_04_NameFirst_AN": "HARRIETT",
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "6666666666",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        }
                      },
                      "ClaimStatusTrackingNumber_Loop_2200D": [
                        {
                          "ClaimStatusTrackingNumber": {
                            "TRN_01_TraceTypeCode_ID": "2",
                            "TRN_02_ReferenceIdentification_AN": "MILLS66666",
                            "TRN_03_OriginatingCompanyIdentifier_AN": null,
                            "TRN_04_ReferenceIdentification_AN": null
                          },
                          "ClaimLevelStatusInformation": [
                            {
                              "STC_01_HealthClaimStatus": {
                                "C043_01_IndustryCode_AN": "DR02",
                                "C043_02_IndustryCode_AN": "20",
                                "C043_03_EntityIdentifierCode_ID": "PR",
                                "C043_04_CodeListQualifierCode_ID": null
                              },
                              "STC_02_Date_DT": "20190221",
                              "STC_03_ActionCode_ID": "WQ",
                              "STC_04_MonetaryAmount_R": "50",
                              "STC_05_MonetaryAmount_R": null,
                              "STC_06_Date_DT": null,
                              "STC_07_PAymentMethodCode_ID": null,
                              "STC_08_Date_DT": null,
                              "STC_09_CheckNumber_AN": null,
                              "STC_10_HealthCareClaimStatus": null,
                              "STC_11_HealthCareClaimStatus": null,
                              "STC_12_FreeformMessageText_AN": null
                            }
                          ],
                          "DataRecieverClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "F8",
                            "REF_02_ReferenceIdentification_AN": "IC429956",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "PayerClaimControlNumber": {
                            "REF_01_ReferenceIdentificationQualifier_ID": "1K",
                            "REF_02_ReferenceIdentification_AN": "220216359807X",
                            "REF_03_Description_AN": null,
                            "REF_04_ReferenceIdentifier": null
                          },
                          "ClaimIdentifiermberForTransmissionIntermediaries": null,
                          "ClaimLevelServiceDate": {
                            "DTP_01_DateTimeQualifier_ID": "472",
                            "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                            "DTP_03_DateTimePeriod_AN": "20190205"
                          },
                          "ServiceLineInformation_Loop_2220D": [
                            {
                              "ServiceLineInformation": null,
                              "ServiceLineLevelStatusInformation": null,
                              "LineItemControlNumber": null,
                              "PharmacyPrescriptionNumber": null,
                              "ServiceLineDate": null
                            }
                          ]
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          },
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "63",
            "SE_02_TransactionSetControlNumber_AN": "0003"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "2",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "161130044"
  }
}

Sample response (Data Reporting Acknowledgment)

EDI 277 Copy

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *220610*1300*^*00501*161130044*0*P*:~GS*HB*SENDER*RECEIVER*20220610*1300*1*X*005010X364~ST*277*0003*005010X364~BHT*0085*08*0000221*20190221*1025~HL*1**20*1~NM1*ACV*2*ALL PAYER CLAIMS DATABASE*****46*APCD01~TRN*1*ABC12345~DTP*050*D8*20190220~DTP*009*D8*20190221~HL*2*1*21*1~NM1*40*2*YOUR INSURANCE COMPANY*****46*S00003~TRN*2*206438976580901~STC*DR02:20*20190221*WQ*365.5~QTY*90*3~QTY*AA*2~AMT*YU*200.5~AMT*YY*165~HL*3*2*19*1~NM1*85*1*JONES*HARRY*B**MD*XX*1546326897~HL*4*3*PT~NM1*QC*1*PATIENT*FEMALE****MI*2222222222~TRN*2*PATIENT22222~STC*DR02:20:PR*20190221*WQ*100~REF*F8*IC847502~REF*1K*220216359803X~DTP*472*D8*20190214~HL*5*3*PT~NM1*QC*1*PATIENT*MALE****MI*3333333333~TRN*2*PATIENT33333~STC*DR06:21*20190221*U*65******DR06:255~REF*F8*IC429783~REF*1K*220216359954X~DTP*472*D8*20190121~HL*6*3*PT~NM1*QC*1*JONES*LARRY****MI*4444444444~TRN*2*JONES44444~STC*DR03:26:77*20190221*U*100~REF*F8*IC429805~REF*1K*220216359964X~DTP*472*D8*20190211~HL*7*2*19*1~NM1*85*1*SMITH*JOHN*C**MD*XX*1546326780~TRN*1*0~REF*LU*AB142~QTY*QA*2~AMT*YU*100.5~HL*8*7*PT~NM1*QC*1*JOHNSON*MARY****MI*5555555555~TRN*2*JOHNSON55555~STC*DR08:20:PR*20190221*EZ*50.5~REF*F8*IC429888~REF*1K*220216359806X~DTP*472*D8*20190210~SVC*HC:G9938*50.5*****1~STC*DR08:475**EZ~REF*6R*1~DTP*472*D8*20190210~HL*9*7*PT~NM1*QC*1*MILLS*HARRIETT****MI*6666666666~TRN*2*MILLS66666~STC*DR02:20:PR*20190221*WQ*50~REF*F8*IC429956~REF*1K*220216359807X~DTP*472*D8*20190205~SE*63*0003~GE*2*1~IEA*1*161130044~

Healthcare EDIs

EDI 270 SJ (Patient Eligibility Request)

EDI 271 SJ (Patient Eligibility Request)

EDI 276 (Claim Status Request)

EDI 277 (Claim Status Response)

EDI 834 (Patient Enrollment)

EDI 835 SJ (Claim Payment and Advice)

EDI 837 (Claims)

Acknowledgment EDIs

EDI 997 SJ (Functional Acknowledgment)

EDI 999 SJ (Implementation Acknowledgment)

Freight and Shipping EDIs

EDI 404 (Rail Carrier Shipment Information)

EDI 410 (Rail Carrier Freight Details and Invoice)