07834 · A requested change is not active coverage
Keep the member, subscriber, employer and payer distinct. Each HD plan belongs to the current INS member, not the previous person in the file.
What to inspect
Read INS and HD maintenance actions, REF family/group identifiers and DTP effective/end dates. Check additions, changes, termination, reinstatement and multiple plans separately.
What to do next
Resolve ambiguous subscriber links, apply effective dates in your enrollment system and reconcile payer acceptance. The preview creates linked records but never activates a policy.
08278 · Keep the decision at the correct level
Authorization review can carry patient-event and service-level information. One event decision must not silently become the decision for every patient or service.
What to inspect
Follow HL parents, NM1 identity, TRN correlation, UM review context and HCR action/reference. A denial or pending review is not a remittance adjustment.
What to do next
Resolve required FHIR fields and the selected PAS version and partner rules. Test partial decisions, corrections and service-level exceptions with de-identified fixtures.
09820 · Allocate premiums without assuming settlement
An 820 can describe payment and allocations to invoices or members. Its business purpose differs from an 835 claim remittance.
What to inspect
Compare BPR payment amount, TRN payment reference, RMR allocations and ADX adjustments. Preserve ENT/member context and do not double-count adjustments.
What to do next
Reconcile allocations, settlement and enrollment as separate processes. Confirm dates, currency and member attribution before posting to a financial system.
01Read the envelope before the payload
Start with ISA/IEA, then GS/GE, then ST/SE. These nested envelopes identify the interchange, functional group and transaction. Preserve delimiters and leading zeros when comparing control numbers.
What to inspect
Check ISA13 ↔ IEA02, GS06 ↔ GE02 and ST02 ↔ SE02. Count ST through SE inclusively. GE counts transactions; IEA counts groups.
What to do next
If a file is truncated, repair the source/export process. Do not silently add trailers to a production message just to make a checker pass.
02270 / 271 · Eligibility is context, not a guarantee
A 270 asks about eligibility and benefits. A 271 returns benefit information or request-validation feedback. Follow payer, provider, subscriber and dependent context rather than reading an EB segment in isolation.
What to inspect
Inspect NM1 identification, HL hierarchy, EQ service type, EB benefit details, DTP dates and any AAA feedback. Match the response to the original inquiry.
What to do next
Confirm service date, network and service-specific benefits. Handle multiple benefit records and inconclusive responses explicitly in the product.
03837 · A claim is more than a charge
Professional, institutional and dental claims use different implementation guides. Billing, rendering and referring providers are different roles. Subscriber and patient may be different people.
What to inspect
Start with the implementation version, then provider/subscriber loops, CLM, diagnosis context and service lines. Professional SV1 and institutional SV2 are not interchangeable.
What to do next
Validate required loops and situational rules with the applicable licensed guide. Add payer-specific edits, enrollment checks and duplicate-submission controls.
04999 / 277CA · Accepted at which stage?
A 999 reports implementation acknowledgment results. A 277CA reports claim acknowledgment information. Passing one stage does not mean the claim has been adjudicated or paid.
What to inspect
Use AK1/AK2 to find the original group and transaction. For a rejected 999, inspect IK3/IK4. For 277CA, correlate the claim and interpret the full STC composite.
What to do next
Store acknowledgments against the outbound submission. Route rejection work to the right owner and keep resubmissions linked to the original attempt.
05276 / 277 · Ask about an existing claim
A 276 requests claim status; its 277 response returns status information. Although 277CA shares the transaction number 277, its implementation guide and purpose differ.
What to inspect
Check ST03/GS08, the request identifiers, service dates and STC status context. A status response is a point-in-time view, not a remittance.
What to do next
Respect trading-partner query criteria and cadence. Model pending, rejected, adjudicated and unknown states separately instead of collapsing them into success/failure.
06835 · Reconcile, then interpret
An 835 describes claim payments and adjustments. Claims, service lines and provider-level adjustments live at different levels; a single payment may span many claims.
What to inspect
Read BPR/TRN for payment context, CLP for claim amounts, SVC for service lines, CAS for adjustments and PLB for provider adjustments. Read CARC with its group code and any remarks.
What to do next
Account for reversals, recoupments, duplicate ERAs and PLB before posting. Match EFT and ERA references; never equate a remittance with confirmed receipt of money.
