X12 276 Health Care Claim Status Request Last updated: 2026-09-29

using EdiFabric.Framework.Readers;
using EdiFabric.Framework.Writers;
using EdiFabric.Templates.Hipaa5010;
using System.Collections.Generic;
using System.IO;
using System.Linq;
using EdiFabric.Core.Model.Edi;
using EdiFabric.Core.Model.Edi.X12;
using EdiFabric.Examples.X12.Common;

namespace EdiFabric.Examples.X12.T276
{
    class Program
    {
        static void Main(string[] args)
        {
            SerialKey.Set(Common.SerialKey.Get());
            Read();
            Write();
        }

        ///
        /// Read Request Transmission
        ///
        static void Read()
        {
            var ediStream = File.OpenRead(Directory.GetCurrentDirectory() + @"\..\..\..\Files\Hipaa\RequestTransmission.txt");

            List ediItems;
            using (var ediReader = new X12Reader(ediStream, "EdiFabric.Templates.Hipaa"))
                ediItems = ediReader.ReadToEnd().ToList();

            var transactions = ediItems.OfType();

            foreach (var transaction in transactions)
            {
                if (transaction.HasErrors)
                {
                    //  partially parsed
                    var errors = transaction.ErrorContext.Flatten();
                }
            }
        }

        ///
        /// Write Request Transmission
        ///
        static void Write()
        {
            var transaction = BuildRequestTransmission("1");

            using (var stream = new MemoryStream())
            {
                using (var writer = new X12Writer(stream))
                {
                    writer.Write(SegmentBuilders.BuildIsa("1"));
                    writer.Write(SegmentBuilders.BuildGs("1", "SENDER1", "RECEIVER1", "005010X212"));
                    writer.Write(transaction);
                }

                var ediString = stream.LoadToString();
            }
        }

        ///
        /// Builds request transmission.
        /// Original from http://www.x12.org/examples/005010X212/claim-level-status/x212-276-claim-request/
        /// Claim 1
        /// Request: Fred Smith is a Medicare enrollee with a health insurance claim number of 123456789A.Mr.Smith's birth date is 12/10/1930.
        /// A claim status tracking number of ABCXYZ1 was assigned to the status inquiry for Mr. Smith's claim.
        /// Home Hospital requested the status of a claim for inpatient services (bill type 111) for services August 31, 2005 through September 6, 2005 in the amount of $8,513.88.
        /// Home Hospital provided a patient control number of SM123456.
        /// Claim 2
        /// Request: Mary Jones is a Medicare enrollee with a health insurance claim number of 234567890A.Mrs.Jones' birth date is 11/15/1930.
        /// A claim status tracking number of ABCXYZ2 was assigned to the status inquiry for Mrs. Jones' claim.
        /// Home Hospital requested the status of a claim for inpatient services (bill type 111) from July 31, 2005 through August 9, 2005 in the amount of $7,599.00.
        /// Home Hospital provided a patient control number of JO234567.
        /// Claim 3
        /// Request: Joseph Mann is a dependent under John Mann's PPO plan. John Mann is the insured, or subscriber, and his member identification is 345678901.
        /// Joseph Mann's birth date is 11/01/1995. A claim status tracking number of ABCXYZ3 was assigned to the status inquiry for Joseph Mann's claim.
        /// Home Hospital Physicians requested the status of a service (99203) on May 1, 2005 in the amount of $150.00.
        /// Home Hospital Physicians provided a patient control number of MA345678.
        ///
        static TS276 BuildRequestTransmission(string controlNumber)
        {
            var result = new TS276();

            result.ST = new ST();
            result.ST.TransactionSetIdentifierCode_01 = "276";
            result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
            result.ST.ImplementationConventionPreference_03 = "005010X212";

            result.BHT_BeginningOfHierarchicalTransaction = new BHT_BeginningOfHierarchicalTransaction_3();
            result.BHT_BeginningOfHierarchicalTransaction.HierarchicalStructureCode_01 = "0010";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetPurposeCode_02 = "13";
            result.BHT_BeginningOfHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "ABC276XXX";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationDate_04 = "20050915";
            result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationTime_05 = "1425";

            //  Repeating 2000A Loops
            result.Loop2000A = new List();

            //  Begin 2000A Loop
            var loop2000A = new Loop_2000A_276();

            loop2000A.HL_InformationSourceLevel = new HL_BillingProviderHierarchicalLevel();
            loop2000A.HL_InformationSourceLevel.HierarchicalIDNumber_01 = "1";
            loop2000A.HL_InformationSourceLevel.HierarchicalLevelCode_03 = "20";
            loop2000A.HL_InformationSourceLevel.HierarchicalChildCode_04 = "1";

            //  Begin 2100A Loop
            loop2000A.Loop2100A = new Loop_2100A_276();

            loop2000A.Loop2100A.NM1_PayerName = new NM1_OtherPayerName();
            loop2000A.Loop2100A.NM1_PayerName.EntityIdentifierCode_01 = "PR";
            loop2000A.Loop2100A.NM1_PayerName.EntityTypeQualifier_02 = "2";
            loop2000A.Loop2100A.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "ABC INSURANCE";
            loop2000A.Loop2100A.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
            loop2000A.Loop2100A.NM1_PayerName.ResponseContactIdentifier_09 = "12345";

            //  End 2100A Loop

            //  Repeating 2000B Loops
            loop2000A.Loop2000B = new List();

            //  Begin 2000B Loop
            var loop2000B = new Loop_2000B_276();

            loop2000B.HL_InformationReceiverLevel = new HL_InformationReceiverLevel();
            loop2000B.HL_InformationReceiverLevel.HierarchicalIDNumber_01 = "2";
            loop2000B.HL_InformationReceiverLevel.HierarchicalParentIDNumber_02 = "1";
            loop2000B.HL_InformationReceiverLevel.HierarchicalLevelCode_03 = "21";
            loop2000B.HL_InformationReceiverLevel.HierarchicalChildCode_04 = "1";

            //  Begin 2100B Loop
            loop2000B.Loop2100B = new Loop_2100B_276();

            loop2000B.Loop2100B.NM1_InformationReceiverName = new NM1_InformationReceiverName_3();
            loop2000B.Loop2100B.NM1_InformationReceiverName.EntityIdentifierCode_01 = "41";
            loop2000B.Loop2100B.NM1_InformationReceiverName.EntityTypeQualifier_02 = "2";
            loop2000B.Loop2100B.NM1_InformationReceiverName.ResponseContactLastorOrganizationName_03 = "XYZ SERVICE";
            loop2000B.Loop2100B.NM1_InformationReceiverName.IdentificationCodeQualifier_08 = "46";
            loop2000B.Loop2100B.NM1_InformationReceiverName.ResponseContactIdentifier_09 = "X67E";

            //  End 2100B Loop

            //  Repeating 2000C Loops
            loop2000B.Loop2000C = new List();

            //  Begin 2000C Loop 1
            var loop2000C1 = new Loop_2000C_276();

            loop2000C1.HL_ServiceProviderLevel = new HL_ServiceProviderLevel();
            loop2000C1.HL_ServiceProviderLevel.HierarchicalIDNumber_01 = "3";
            loop2000C1.HL_ServiceProviderLevel.HierarchicalParentIDNumber_02 = "2";
            loop2000C1.HL_ServiceProviderLevel.HierarchicalLevelCode_03 = "19";
            loop2000C1.HL_ServiceProviderLevel.HierarchicalChildCode_04 = "1";

            //  Repeating 2100C Loops
            loop2000C1.Loop2100C = new List();

            //  Begin 2100C Loop
            var loop2100C = new Loop_2100C_276();

            loop2100C.NM1_ProviderName = new NM1_ProviderName();
            loop2100C.NM1_ProviderName.EntityIdentifierCode_01 = "1P";
            loop2100C.NM1_ProviderName.EntityTypeQualifier_02 = "2";
            loop2100C.NM1_ProviderName.ResponseContactLastorOrganizationName_03 = "HOME HOSPITAL";
            loop2100C.NM1_ProviderName.IdentificationCodeQualifier_08 = "XX";
            loop2100C.NM1_ProviderName.ResponseContactIdentifier_09 = "1666666661";

            //  End 2100C Loop
            loop2000C1.Loop2100C.Add(loop2100C);

            //  Repeating 2000D Loops
            loop2000C1.Loop2000D = new List();

            //  Begin 2000D Loop 1
            var loop2000D1 = new Loop_2000D_276();

            loop2000D1.HL_SubscriberLevel = new HL_SubscriberHierarchicalLevel();
            loop2000D1.HL_SubscriberLevel.HierarchicalIDNumber_01 = "4";
            loop2000D1.HL_SubscriberLevel.HierarchicalParentIDNumber_02 = "3";
            loop2000D1.HL_SubscriberLevel.HierarchicalLevelCode_03 = "22";
            loop2000D1.HL_SubscriberLevel.HierarchicalChildCode_04 = "0";

            loop2000D1.DMG_SubscriberDemographicInformation = new DMG_DependentDemographicInformation_3();
            loop2000D1.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
            loop2000D1.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19301210";
            loop2000D1.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "M";

            //  Begin 2100D Loop
            loop2000D1.Loop2100D = new Loop_2100D_276();

            loop2000D1.Loop2100D.NM1_SubscriberName = new NM1_SubscriberName_2();
            loop2000D1.Loop2100D.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
            loop2000D1.Loop2100D.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
            loop2000D1.Loop2100D.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "SMITH";
            loop2000D1.Loop2100D.NM1_SubscriberName.ResponseContactFirstName_04 = "FRED";
            loop2000D1.Loop2100D.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
            loop2000D1.Loop2100D.NM1_SubscriberName.ResponseContactIdentifier_09 = "123456789A";

            //  End 2100D Loop

            //  Repeating 2200D Loops
            loop2000D1.Loop2200D = new List();

            //  Begin 2200D Loop
            var loop2200D = new Loop_2200D_276();

            loop2200D.TRN_ClaimStatusTrackingNumber = new TRN_ClaimStatusTrackingNumber();
            loop2200D.TRN_ClaimStatusTrackingNumber.TraceTypeCode_01 = "1";
            loop2200D.TRN_ClaimStatusTrackingNumber.CurrentTransactionTraceNumber_02 = "ABCXYZ1";

            //  Occurrence of REF Segments in any order
            loop2200D.AllREF = new All_REF_276();

            loop2200D.AllREF.REF_InstitutionalBillTypeIdentification = new REF_InstitutionalBillTypeIdentification();
            loop2200D.AllREF.REF_InstitutionalBillTypeIdentification.ReferenceIdentificationQualifier_01 = "BLT";
            loop2200D.AllREF.REF_InstitutionalBillTypeIdentification.MemberGrouporPolicyNumber_02 = "111";

            loop2200D.AllREF.REF_PatientControlNumber = new REF_PatientControlNumber();
            loop2200D.AllREF.REF_PatientControlNumber.ReferenceIdentificationQualifier_01 = "EJ";
            loop2200D.AllREF.REF_PatientControlNumber.MemberGrouporPolicyNumber_02 = "SM123456";

            loop2200D.AMT_ClaimSubmittedCharges = new AMT_ClaimSubmittedCharges();
            loop2200D.AMT_ClaimSubmittedCharges.AmountQualifierCode_01 = "T3";
            loop2200D.AMT_ClaimSubmittedCharges.TotalClaimChargeAmount_02 = "8513.88";

            loop2200D.DTP_ClaimServiceDate = new DTP_ClaimLevelServiceDate();
            loop2200D.DTP_ClaimServiceDate.DateTimeQualifier_01 = "472";
            loop2200D.DTP_ClaimServiceDate.DateTimePeriodFormatQualifier_02 = "RD8";
            loop2200D.DTP_ClaimServiceDate.DateTimePeriod_03 = "20050831-20050906";

            //  End 2200D Loop
            loop2000D1.Loop2200D.Add(loop2200D);

            //  End 2000D Loop 1
            loop2000C1.Loop2000D.Add(loop2000D1);

            //  Begin 2000D Loop 2
            var loop2000D2 = new Loop_2000D_276();

            loop2000D2.HL_SubscriberLevel = new HL_SubscriberHierarchicalLevel();
            loop2000D2.HL_SubscriberLevel.HierarchicalIDNumber_01 = "5";
            loop2000D2.HL_SubscriberLevel.HierarchicalParentIDNumber_02 = "3";
            loop2000D2.HL_SubscriberLevel.HierarchicalLevelCode_03 = "22";
            loop2000D2.HL_SubscriberLevel.HierarchicalChildCode_04 = "0";

            loop2000D2.DMG_SubscriberDemographicInformation = new DMG_DependentDemographicInformation_3();
            loop2000D2.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
            loop2000D2.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19301115";
            loop2000D2.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "F";

            //  Begin 2100D Loop
            loop2000D2.Loop2100D = new Loop_2100D_276();

            loop2000D2.Loop2100D.NM1_SubscriberName = new NM1_SubscriberName_2();
            loop2000D2.Loop2100D.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
            loop2000D2.Loop2100D.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
            loop2000D2.Loop2100D.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "JONES";
            loop2000D2.Loop2100D.NM1_SubscriberName.ResponseContactFirstName_04 = "MARY";
            loop2000D2.Loop2100D.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
            loop2000D2.Loop2100D.NM1_SubscriberName.ResponseContactIdentifier_09 = "234567890A";

            //  End 2100D Loop

            //  Repeating 2200D Loops
            loop2000D2.Loop2200D = new List();

            //  Begin 2200D Loop
            var loop2200D2 = new Loop_2200D_276();

            loop2200D2.TRN_ClaimStatusTrackingNumber = new TRN_ClaimStatusTrackingNumber();
            loop2200D2.TRN_ClaimStatusTrackingNumber.TraceTypeCode_01 = "1";
            loop2200D2.TRN_ClaimStatusTrackingNumber.CurrentTransactionTraceNumber_02 = "ABCXYZ2";

            //  Occurrence of REF Segments in any order
            loop2200D2.AllREF = new All_REF_276();

            loop2200D2.AllREF.REF_InstitutionalBillTypeIdentification = new REF_InstitutionalBillTypeIdentification();
            loop2200D2.AllREF.REF_InstitutionalBillTypeIdentification.ReferenceIdentificationQualifier_01 = "BLT";
            loop2200D2.AllREF.REF_InstitutionalBillTypeIdentification.MemberGrouporPolicyNumber_02 = "111";

            loop2200D2.AllREF.REF_PatientControlNumber = new REF_PatientControlNumber();
            loop2200D2.AllREF.REF_PatientControlNumber.ReferenceIdentificationQualifier_01 = "EJ";
            loop2200D2.AllREF.REF_PatientControlNumber.MemberGrouporPolicyNumber_02 = "JO234567";

            loop2200D2.AMT_ClaimSubmittedCharges = new AMT_ClaimSubmittedCharges();
            loop2200D2.AMT_ClaimSubmittedCharges.AmountQualifierCode_01 = "T3";
            loop2200D2.AMT_ClaimSubmittedCharges.TotalClaimChargeAmount_02 = "7599";

            loop2200D2.DTP_ClaimServiceDate = new DTP_ClaimLevelServiceDate();
            loop2200D2.DTP_ClaimServiceDate.DateTimeQualifier_01 = "472";
            loop2200D2.DTP_ClaimServiceDate.DateTimePeriodFormatQualifier_02 = "RD8";
            loop2200D2.DTP_ClaimServiceDate.DateTimePeriod_03 = "20050731-20050809";

            //  End 2200D Loop
            loop2000D2.Loop2200D.Add(loop2200D2);

            //  End 2000D Loop 2
            loop2000C1.Loop2000D.Add(loop2000D2);

            //  End 2000C Loop 1
            loop2000B.Loop2000C.Add(loop2000C1);

            //  Begin 2000C Loop 2
            var loop2000C2 = new Loop_2000C_276();

            loop2000C2.HL_ServiceProviderLevel = new HL_ServiceProviderLevel();
            loop2000C2.HL_ServiceProviderLevel.HierarchicalIDNumber_01 = "6";
            loop2000C2.HL_ServiceProviderLevel.HierarchicalParentIDNumber_02 = "2";
            loop2000C2.HL_ServiceProviderLevel.HierarchicalLevelCode_03 = "19";
            loop2000C2.HL_ServiceProviderLevel.HierarchicalChildCode_04 = "1";

            //  Repeating 2100C Loops
            loop2000C2.Loop2100C = new List();

            //  Begin 2100C Loop
            var loop2100C2 = new Loop_2100C_276();

            loop2100C2.NM1_ProviderName = new NM1_ProviderName();
            loop2100C2.NM1_ProviderName.EntityIdentifierCode_01 = "1P";
            loop2100C2.NM1_ProviderName.EntityTypeQualifier_02 = "2";
            loop2100C2.NM1_ProviderName.ResponseContactLastorOrganizationName_03 = "HOME HOSPITAL PHYSICIANS";
            loop2100C2.NM1_ProviderName.IdentificationCodeQualifier_08 = "XX";
            loop2100C2.NM1_ProviderName.ResponseContactIdentifier_09 = "1666666666";

            //  End 2100C Loop
            loop2000C2.Loop2100C.Add(loop2100C2);

            //  Repeating 2000D Loops
            loop2000C2.Loop2000D = new List();

            //  Begin 2000D Loop 1
            var loop2000D3 = new Loop_2000D_276();

            loop2000D3.HL_SubscriberLevel = new HL_SubscriberHierarchicalLevel();
            loop2000D3.HL_SubscriberLevel.HierarchicalIDNumber_01 = "7";
            loop2000D3.HL_SubscriberLevel.HierarchicalParentIDNumber_02 = "6";
            loop2000D3.HL_SubscriberLevel.HierarchicalLevelCode_03 = "22";
            loop2000D3.HL_SubscriberLevel.HierarchicalChildCode_04 = "1";

            //  Begin 2100D Loop
            loop2000D3.Loop2100D = new Loop_2100D_276();

            loop2000D3.Loop2100D.NM1_SubscriberName = new NM1_SubscriberName_2();
            loop2000D3.Loop2100D.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
            loop2000D3.Loop2100D.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
            loop2000D3.Loop2100D.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "MANN";
            loop2000D3.Loop2100D.NM1_SubscriberName.ResponseContactFirstName_04 = "JOHN";
            loop2000D3.Loop2100D.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
            loop2000D3.Loop2100D.NM1_SubscriberName.ResponseContactIdentifier_09 = "345678901";

            //  End 2100D Loop

            //  Repeating 2000E Loops
            loop2000D3.Loop2000E = new List();

            //  Begin 2000E Loop
            var loop2000E = new Loop_2000E_276();

            loop2000E.HL_DependentLevel = new HL_DependentLevel_2();
            loop2000E.HL_DependentLevel.HierarchicalIDNumber_01 = "8";
            loop2000E.HL_DependentLevel.HierarchicalParentIDNumber_02 = "7";
            loop2000E.HL_DependentLevel.HierarchicalLevelCode_03 = "23";

            loop2000E.DMG_DependentDemographicInformation = new DMG_DependentDemographicInformation_3();
            loop2000E.DMG_DependentDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
            loop2000E.DMG_DependentDemographicInformation.DependentBirthDate_02 = "19951101";
            loop2000E.DMG_DependentDemographicInformation.DependentGenderCode_03 = "M";

            //  Begin 2100E Loop
            loop2000E.Loop2100E = new Loop_2100E_276();

            loop2000E.Loop2100E.NM1_DependentName = new NM1_DependentName_2();
            loop2000E.Loop2100E.NM1_DependentName.EntityIdentifierCode_01 = "QC";
            loop2000E.Loop2100E.NM1_DependentName.EntityTypeQualifier_02 = "1";
            loop2000E.Loop2100E.NM1_DependentName.ResponseContactLastorOrganizationName_03 = "MANN";
            loop2000E.Loop2100E.NM1_DependentName.ResponseContactFirstName_04 = "JOSEPH";

            //  End 2100E Loop

            //  Repeating 2200E Loops
            loop2000E.Loop2200E = new List();

            //  Begin 2200E Loop
            var loop2200E = new Loop_2200E_276();

            loop2200E.TRN_ClaimStatusTrackingNumber = new TRN_ClaimStatusTrackingNumber();
            loop2200E.TRN_ClaimStatusTrackingNumber.TraceTypeCode_01 = "1";
            loop2200E.TRN_ClaimStatusTrackingNumber.CurrentTransactionTraceNumber_02 = "ABCXYZ3";

            //  Occurrence of REF Segments in any order
            loop2200E.AllREF = new All_REF_276();

            loop2200E.AllREF.REF_PatientControlNumber = new REF_PatientControlNumber();
            loop2200E.AllREF.REF_PatientControlNumber.ReferenceIdentificationQualifier_01 = "EJ";
            loop2200E.AllREF.REF_PatientControlNumber.MemberGrouporPolicyNumber_02 = "MA345678";

            //  Repeating 2210E Loops
            loop2200E.Loop2210E = new List();

            //  Begin 2210E Loop
            var loop2210E = new Loop_2210E_276();

            loop2210E.SVC_ServiceLineInformation = new SVC_ServiceLineInformation();
            loop2210E.SVC_ServiceLineInformation.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_6();
            loop2210E.SVC_ServiceLineInformation.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
            loop2210E.SVC_ServiceLineInformation.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "99203";
            loop2210E.SVC_ServiceLineInformation.LineItemChargeAmount_02 = "150";
            loop2210E.SVC_ServiceLineInformation.UnitsofServiceCount_07 = "1";

            loop2210E.DTP_ServiceLineDate = new DTP_ClaimLevelServiceDate();
            loop2210E.DTP_ServiceLineDate.DateTimeQualifier_01 = "472";
            loop2210E.DTP_ServiceLineDate.DateTimePeriodFormatQualifier_02 = "D8";
            loop2210E.DTP_ServiceLineDate.DateTimePeriod_03 = "20050501";

            //  End 2210E Loop
            loop2200E.Loop2210E.Add(loop2210E);

            //  End 2200E Loop
            loop2000E.Loop2200E.Add(loop2200E);

            //  End 2000E Loop
            loop2000D3.Loop2000E.Add(loop2000E);

            //  End 2000D Loop 2
            loop2000C2.Loop2000D.Add(loop2000D3);

            //  End 2000C Loop 2
            loop2000B.Loop2000C.Add(loop2000C2);

            //  End 2000B Loop
            loop2000A.Loop2000B.Add(loop2000B);

            //  End 2000A Loop
            result.Loop2000A.Add(loop2000A);

            return result;
        }
    }
}