Claim Status Inquiry and Response 276 and 277

For health care service providers 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:

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.

CalOptima uses this to respond to an 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:

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.

Electronic claim status transactions may have these benefits:

CalOptima will acknowledge 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 and 277 transactions in real-time mode, based on connectivity method.

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.

As a provider, you may call the CalOptima Claims department at 714-246-8885 to verify member claim status.