Claim Status Inquiry and Response (276/277)

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Questions




If you have questions or need assistance, call our Provider Relations Department at:

1-714-246-8600

Monday through Friday from 8 a.m. to 4 p.m. Pacific Time

When Should Providers Use Claim Status Inquiry and Response?

EDI Health Care Claim Status Inquiry (276) is what health care service providers use to inquire about the status of a claim or claims submitted to CalOptima for payment consideration, either on paper or electronically.

HIPAA specifies the 276 transaction for the electronic submission of claim status requests. The transaction typically includes:

  • Provider identification
  • Member identification
  • Member information
  • Date(s) of service(s)
  • Charges

Submitting a 276 status request to CalOptima is your first step in the claim status request/response process. CalOptima provides the response to the requested information using a 277 Claims Status Response transaction.

EDI Health Care Claim Status Response (277) is what CalOptima uses when responding to a requested inquiry from a health care service provider about the status of a claim or claims submitted to CalOptima, either on paper or electronically, for payment consideration.

The 277 transaction, specified by HIPAA for the submission of claim status information, can be used in one of the following three ways:

  • A 277 transaction may be sent in response to a previously received 276 Claim Inquiry

  • CalOptima may use a 277 to request additional information about a submitted claim (without a 276)

  • CalOptima may provide claim status information to a health care service provider using the 277, without receiving a 276

Information provided in a 277 transaction generally indicates where the claim is in process, either as Pending or Finalized. If finalized, the transaction will indicate the disposition of the claim: rejected, denied, approved for payment or paid.

The 277 may also indicate the claim approval or paid status, as well as payment information, such as method, date, amount, etc. If denied or rejected the transaction may include an explanation, such as if the patient is not eligible.

What Are The Benefits?

Electronic claim status transactions may result in the following benefits:

  • Increased productivity and efficiency

  • Less time spent on manual, administrative tasks

  • Decreased duplicate claim submissions

CalOptima will acknowledge the of receipt of all electronic claims within two working days and paper claims within 15 working days. Providers should not interpret the acknowledgement of a claim as a guarantee of payment. Payment of benefits remains subject to all health plan benefit terms, limits, conditions, exclusions and the member’s eligibility at the time the provider renders services.

Providers can perform claim status (276/277) transactions in real-time mode, based on connectivity method.

Getting Started

For an overview of how this process works and the user agreements that may be required prior to activation, visit the Office Ally website for Claim Status Requests.

If you have questions about real-time transactions, contact the Office Ally Customer Service department at 360-975-7000.

Other Resources

As a Provider, you may call the CalOptima Claims department at 888-587-8088 as an additional resource to verify member claim status.

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