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Healthcare claim status request message processing

Updated on April 23, 2021

The Foundation provides preconfigured rules to process real-time 276 Claim Status Request messages. The X12 parsing rules are configured per the X12 276/277 Healthcare Claim Status Request & Response Implementation Guide and support batch, as well as real-time message processing.

Pega Foundation for Healthcare

The sample scenarios included in the Foundation reflect a real-time processing situation with an immediate response generated after processing the message. To reflect this real-time situation, the messages are limited to one claim status request per member (subscriber or patient).

As per the X12 276/277 Implementation Guide specification, there is no validation at the various levels of the message loops.

The key functionality includes:

  • X12 276 Message Parsing — per the 276/277 Implementation Guide.
  • Claim Status Request Work Object Creation — for every claim submitted in the transaction.
  • Claim Retrieval — sample business rules to retrieve a claim from the sample database based on the Claim Identifiers submitted on the 276 message. If a matching claim is not found, an appropriate STC segment is returned on the outbound 277 message. If a matching claim is found, the system returns the claim status information in the STC segment of the 277 message.
  • X12 277 Message Generation — per the 2760/277 Implementation Guide.
  • Previous topic Key rules for eligibility request and response message
  • Next topic Key rules for claims status request and response message

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