Health Care Services Review Information - Response (X217)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231120*0454*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20231120*045435*000000001*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*11*A12345*20050502*1102*18~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~
HL*2*1*21*1~
NM1*1P*1*GARDENER*JAMES****46*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*0~
TRN*2*111099*9012345678~
UM*SC*I*3*11>B~
HCR*A1*AUTH0001~
DTP*AAH*RD8*20050502-20050602~
HI*BF>41090>D8>20050430~
HSD*VS*1~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PER*IC**TE*4029993456~
SE*18*0001~
GE*1*000000001~
IEA*1*000000001~

Example 1: Response to the Request for Review

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231120*0454*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20231120*045450*000000001*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*11*B56789*20050502*1431*18~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*7893122~
HL*2*1*21*1~
NM1*1P*1*WATSON*SUSAN****34*987654~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*123456789011~
HL*4*3*EV*1~
TRN*2*97021001*9012345678~
UM*AR*I*2*21>B~
HCR*A6*AUTH0002~
DTP*435*D8*20050516~
HI*BF>41090>D8>20050125~
HSD*DY*5~
NM1*FA*2*MONTGOMERY HOSPITAL*****24*000012121~
N3*475 MAIN STREET~
N4*ANYTOWN*PA*19087~
HL*5*4*SS*0~
UM*HS*I*2~
HCR*A1*AUTH0002~
DTP*472*D8*20050516~
SV2**HC>33510~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PRV*PE*PXC*203BS0133X~
SE*26*0001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Response to the Admission Request for Review

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231120*0455*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20231120*045517*000000001*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*11*YZZ345*20050502*1102*19~
HL*1**20*1~
NM1*X3*2*CAPITAL INSURANCE COMPANY*****46*789312~
PER*IC**TE*3936533000~
HL*2*1*21*1~
NM1*FA*2*GENERAL HOSPITAL*****46*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*MARY****MI*12345678901~
HL*4*3*EV*0~
TRN*2*YZZ099*9876543210~
UM*AR*I*A4*21>B**03~
HCR*A4**0U~
REF*NT*P20030216001~
HI*BF>29603>D8>20050429~
PWK*AS*VO~
NM1*FA*2*GENERAL HOSPITAL*****46*987654321~
NM1*71*1*JONES*MARCUS****24*453667654~
NM1*SJ*1*BROWN*JACOB****24*123454545~
SE*20*0001~
GE*1*000000001~
IEA*1*000000001~

Example 3: Response to Request for Behavioral Health Emergency Admission

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231120*0455*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20231120*045538*000000001*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*11*165932*20050502*0815*18~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*1234560010~
HL*2*1*21*1~
NM1*1P*1*XYZ AMBULANCE SVC*****24*7759621873~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
REF*EJ*6532214A76~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*HS*I*56*41>B~
HCR*A1*2005010796321~
DTP*AAH*D8*20050510~
CR1***X**DH*27~
NM1*PW*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
NM1*ND*2*DR. GARDNER OFFICE~
N3*1921 FULTON AVENUE~
N4*SACRAMENTO*CA*95624~
NM1*R3*2*XYZ DIALYSIS CENTER~
N3*7622 MORSETOWN ROAD~
N4*SACRAMENTO*CA*95826~
NM1*FS*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
HL*5*4*SS*0~
SV1*HC>A0428>RX**UN*5~
HL*6*4*SS*0~
SV1*HC>A0428>PD**UN*8~
HL*7*4*SS*0~
SV1*HC>A0428>DR**UN*14~
SE*34*0001~
GE*1*000000001~
IEA*1*000000001~

Example 5: Response to Non-emergency Transportation

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231120*0456*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20231120*045628*000000001*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*11*5269367*20050502*0859*RU~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*1234560010~
HL*2*1*21*1~
NM1*1P*1*GARDNER*JAMES****24*0010102364~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*IN*I*1*11>B~
HCR*A1*6735172961~
HL*5*4*SS*0~
DTP*472*D8*20050110~
SV1*HC>99212**UN*1~
HSD*****29*2~
SE*17*0001~
GE*1*000000001~
IEA*1*000000001~


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X12 278 Health Care Services Review Information - Response (X217)