EDI 275 X211 - Patient Information

Functional Group PI

X12N Insurance Subcommittee

j4

Heading

1. 0100 · ST · 275 Transaction Header · Max 1 · Mandatory

   To indicate the start of a transaction set and to assign a control number

2. 0200 · BGN · Beginning Segment · Max 1 · Mandatory

   To indicate the beginning of a transaction set

3. 1000A Loop Mandatory Repeat 1

   1. 0500 · NM1 · Information Source Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

      Use this NM1 loop to identify the source of the additional information, that is, is the creator and sender of the 275.
      When BGN01 = 02 or 22, this NM1 loop identifies the person or organization that initiated providing this patient information.

   2. 0900 · PER · Information Source Contact Information · Max 1 · Optional

      To identify a person or office to whom administrative communications should be directed

      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g.(534)224-2525 would be represented as 5342242525). The extension when applicable, should be included in the communication number immediately after the telephone number.
      Required when BGN01=02 or BGN01=22 and the name of the individual to contact is different than the name within the prior name segment (i.e., NM1). Required when BGN01 = 11 and the information source wants to direct further contacts to a designated site. If not required by this implementation guide, do not send.

   3. 1000 · REF · Provider Secondary Information · Max 1 · Optional

      To specify identifying information

      Required when a secondary Identification number is necessary to identify the entity. The primary identification number should be reported in NM108/09 in this loop. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
      If the reason the number being used in this REF can be met by the NPI, reported in the NM108/09 of this loop, then this REF is not used.

4. 1000B Loop Mandatory Repeat 1

   1. 0500 · NM1 · Information Receiver Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

      Use this segment to identify the receiver of this 275 and supportive information. When BGN02 = 02 or 11 this is the UMO receiving the 275 supporting the 278 Health Care Services Review Request. When BGN02 = 22 it is the entity receiving the 278 Health Care Services Review Notification.

   2. 0900 · PER · Information Receiver Contact Information · Max 1 · Optional

      To identify a person or office to whom administrative communications should be directed

      Required when the value in BGN01=11 and the Health Care Services Review 278 Response designates a specific contact for the return of the requested information. Required when the BGN01 = 02 or 22 and the specific contact is known to the source of the information. If not required by this implementation guide do not send.

   3. 1000 · REF · Provider Secondary Information · Max 1 · Optional

      To specify identifying information

      Required when a secondary Identification number is necessary to identify the entity. The primary identification number should be reported in NM108/09 in this loop. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
      If the reason the number being used in this REF can be met by the NPI, reported in the NM108/09 of this loop, then this REF is not used.

5. 1000C Loop Mandatory Repeat 1

   1. 0500 · NM1 · Patient Name · Max 1 · Mandatory

      To supply the full name of an individual or organizational entity

      Use this segment to identify the patient as identified in the 278 Health Care Services Review associated with this 275 attachment.
      If the subscriber is the patient, use NM101 = "IL". If the dependent is the patient, use NM101 = "QC".

   2. 1000 · REF · Patient Account Number · Max 1 · Optional

      To specify identifying information

      Required when the REF segment with the Patient Account Number is supplied in the associated 278 transaction. If not required by this implementation guide, do not send.

   3. 1000 · REF · Patient Event Tracking Number · Max 1 · Optional

      To specify identifying information

      Required when the Patient Event Tracking Number appears in the TRN segment of the associated 278. If not required by this implementation guide, do not send.
      In the unsolicited 275, this is the trace number assigned by the information source in the 2000E Loop of the 278.
      In the solicited 275, this may be the number provided in the original 278 Request, or a TRN added by the UMO in the 278 Response.

Detail

1. 2000A Loop Mandatory Repeat >1

   1. 0100 · LX · Assigned Number · Max 1 · Mandatory

      To reference a line number in a transaction set

      The LX segment begins the detailed additional information loop. This loop occurs - once for each response to each request for additional information (each LOINC® and/or each Attachment Control Number) contained in the Health Care Services Review Response or - once for each type of additional information associated with the unsolicited 278 Health Care Services Review Request or - once for each type of additional information associated with the 278 Health Care Services Review Notification.
      Within the LX, LX01 is the sequence number of the LX Loop. It is required that the LX01 sequence number start at 1 and increment by 1.

   2. 0150 · TRN · Attachment Control Number · Max 1 · Mandatory

      To uniquely identify a transaction to an application

      If this 275 is sent in response to the UMO's request for additional information, enter the TRN with the Attachment Control Number assigned by the UMO. This is the number that appears in PWK06 of the associated PWK segment in the Health Care Services Review Reponse.
      If this 275 is sent as an unsolicited attachment for a 278 Health Care Services Review Request or Notification, enter the TRN with the Attachment Control Number that appears in PWK06 of the 278 Health Care Services Review Request or Notification.

   3. 0175 · STC · Status Information · Max 1 · Optional

      To report the status, required action, and paid information of a claim or service line

      This segment must be used to return the question that originally was sent in the request for additional information.
      Required when the transaction is used as a response to a 278 Health Care Services Review Response requesting additional information. If not required by this implementation guide, do not send.

   4. 0500 · REF · Diagnosis Code · Max 1 · Optional

      To specify identifying information

      Required when the 275 is sent unsolicited in support of a 278 request or notification, and the information pertains to a specific diagnosis. If not required by this implementation guide, do not send.

   5. 0500 · REF · Service Trace Number · Max 1 · Optional

      To specify identifying information

      Required when the additional information pertains to specific services, procedures, or treatments originally referenced in the 278 and the 278 contains a Service Trace Number in the associated Service loop. If not required by this implementation guide, do not send.

   6. 0500 · REF · Procedure or Revenue Code · Max 1 · Optional

      To specify identifying information

      Required when the additional information is associated with a specific service/procedure. This matches the procedure code value in the 278 Health Care Services Review Service Loop Procedures Segment. If not required by this implementation guide, do not send.

   7. 2100A Loop Mandatory Repeat 1

      1. 0600 · DTP · Date Additional Information Was Submitted · Max 1 · Mandatory

         To specify any or all of a date, a time, or a time period

      2. 0700 · CAT · Category of Additional Information · Max 1 · Mandatory

         To specify categories of patient information service

      3. 2110A Loop Mandatory Repeat 1

         1. 0900 · EFI · Electronic Format Identification · Max 1 · Mandatory

            To provide basic information about the electronic format of the interchange data

         2. 1000 · BIN · Binary Data Segment · Max 1 · Mandatory

            To transfer binary data in a single data segment and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment

            This segment is used to send information in an HL7 CDA standard format as referenced in the CAT Segment.
            This segment is used for applications not adopted under HIPAA to send additional information in an Electronic Image format when the value of CAT02 = IA.
            It is recommended that BIN02 not exceed 64 megabytes.

2. 1100 · SE · 275 Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)