EDI 278 X217 - Health Care Services Review Information - Review

Functional Group HI

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review. Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.

Heading

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

    Use this segment to indicate the start of a health care services review request transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management request.
  2. To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

Detail

Position
Segment
Name
Max use
  1. 2000A Loop Mandatory
    Repeat 1
    1. To identify dependencies among and the content of hierarchically related groups of data segments

      This segment indicates the information source hierarchical level. For a request transaction, this segment corresponds to the identification of the payer, HMO, or other utilization management organization who will be the source of the decision/response.
    2. 2010A Loop Mandatory
      Repeat 1
      1. To supply the full name of an individual or organizational entity

        This segment identifies the source of information. In the case of a request transaction, the source of information would normally be the payer or utilization review organization making the decision on the request.
    3. 2000B Loop Mandatory
      Repeat 1
      1. To identify dependencies among and the content of hierarchically related groups of data segments

        This segment indicates the health care services review information receiver. For request transactions, this segment corresponds to the identification of the entity initiating the request for review.
      2. 2010B Loop Mandatory
        Repeat 1
        1. To supply the full name of an individual or organizational entity

          This segment identifies the receiver of information. In the case of a request transaction, the receiver would normally be the entity who will ultimately be receiving the decision.
        2. To specify identifying information

          Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider; OR Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity. If not required by this implementation guide, do not send.
        3. To specify the location of the named party

          Use to identify a specific location when the requester has multiple locations and authority varies based on location.
          Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
        4. To specify the geographic place of the named party

          Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
        5. To identify a person or office to whom administrative communications should be directed

          Required when the UMO must direct requests for additional information to a specific requester contact, electronic mail, facsimile, or telephone number. If not required by this implementation guide, do not send.
          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 telephone 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.
        6. To specify the identifying characteristics of a provider

          Required when needed to indicate the requester's role in the care of the patient and the requesting provider's specialty. If not required by this implementation guide, do not send.
      3. 2000C Loop Mandatory
        Repeat 1
        1. To identify dependencies among and the content of hierarchically related groups of data segments

          This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.
        2. 2010C Loop Mandatory
          Repeat 1
          1. To supply the full name of an individual or organizational entity

            This segment conveys the name and identification number of the subscriber (who may also be the patient).
            The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows: Subscriber Last Name (NM103) Subscriber First Name (NM104) Subscriber Birth Date (DMG01 and DMG02)
            Refer to Section 2.2.2.1 Identifying the Patient for specific information on how to identify an individual to a UMO.
          2. To specify identifying information

            Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.
            The primary identifier is the Member Identification Number in the NM1 segment.
            Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
            If the requester values this segment with the Patient Account Number (REF01="EJ") on the request, the UMO is required to return the same value in this segment on the response.
          3. To specify the location of the named party

            Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
          4. To specify the geographic place of the named party

            Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
          5. To supply demographic information

            Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
            Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
          6. To provide benefit information on insured entities

            Required when the subscriber's role in the military is necessary to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
        3. 2000D Loop Optional
          Repeat 1
          1. To identify dependencies among and the content of hierarchically related groups of data segments

            If the patient has a unique member ID, use Loop 2000C to identify the patient.
            Required segments in this loop are required only when this loop is used.
            Required when the patient is someone other than the subscriber and the patient does not have a unique (different from the subscriber) member ID. If not required by this implementation guide, do not send.
          2. 2010D Loop Mandatory
            Repeat 1
            1. To supply the full name of an individual or organizational entity

              This segment conveys the name of the dependent who is the patient.
              The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows: Dependent Last Name (NM103) Dependent First Name (NM104) Dependent Birth Date (DMG01 and DMG02)
              Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
            2. To specify identifying information

              Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
              If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.
              Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
            3. To specify the location of the named party

              Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
            4. To specify the geographic place of the named party

              Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
            5. To supply demographic information

              Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
              Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
            6. To provide benefit information on insured entities

              Required when patient relationship to insured or birth sequence is needed by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
              This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.
          3. 2000E Loop Mandatory
            Repeat 1
            1. To identify dependencies among and the content of hierarchically related groups of data segments

              Loop 2000E to provide information on the patient event associated with this health care services review.
            2. To uniquely identify a transaction to an application

              Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
              This enables the requester to - uniquely identify this patient event request - trace the request - match the response to the request - reference this request in any associated attachments containing additional patient information related to this patient event request.
              If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
              Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
            3. To specify health care services review information

              This segment identifies the type of health care services review request.
            4. To specify identifying information

              This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
              Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.
            5. To specify identifying information

              Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
            6. To specify any or all of a date, a time, or a time period

              Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
            7. To specify any or all of a date, a time, or a time period

              Required when the certification is pregnancy related. If not required by this implementation guide, do not send.
            8. To specify any or all of a date, a time, or a time period

              Required when the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
            9. To specify any or all of a date, a time, or a time period

              Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
            10. To specify any or all of a date, a time, or a time period

              Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
              If UM01 = AR use Admit Date.
            11. To specify any or all of a date, a time, or a time period

              Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
            12. To specify any or all of a date, a time, or a time period

              Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
            13. To supply information related to the delivery of health care

              Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.
            14. To specify the delivery pattern of health care services

              An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
              Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
            15. To supply information on conditions

              Required when health care services review is requesting ambulance certification. If not required by this implementation guide, do not send.
            16. To supply information on conditions

              Required when health care services review is requesting chiropractic certification. If not required by this implementation guide, do not send.
            17. To supply information on conditions

              Required when health care services is requesting durable medical equipment. If not required by this implementation guide, do not send.
            18. To supply information on conditions

              Required when health care services review is requesting oxygen therapy certification. If not required by this implementation guide, do not send.
            19. To supply information on conditions

              Required when the assessing provider has defined function limitation for the patient. If not required by this implementation guide, do not send.
            20. To supply information on conditions

              Required when the assessing provider has defined activities permitted for the patient. If not required by this implementation guide, do not send.
            21. To supply information on conditions

              Required when the patient mental status is relevant to the health care services review. If not required by this implementation guide, do not send.
            22. To supply information specific to hospital claims

              Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
            23. To supply information related to the ambulance service rendered to a patient

              Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
              When the CR1 segment is used, then Loop 2010EB is required.
            24. To supply information related to the chiropractic service rendered to a patient

              Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
            25. To supply information regarding certification of medical necessity for home oxygen therapy

              Required when requesting initial, extended, or revised certification of;home oxygen therapy. If not required by this implementation guide, do not send.
              Use the UM segment data element UM02 instead of CR501 to specify the;Certification Type Code.
              Use the HSD segment instead of CR502 to specify the treatment period.
            26. To supply information related to the certification of a home health care patient

              Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
              Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
            27. To identify the type or transmission or both of paperwork or supporting information

              Required when needed to report missing teeth on requests for dental services, or if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
              This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
              The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA. Refer to Section 2.5 for more information on using this PWK segment.
            28. To provide a free-form format that allows the transmission of text information

              Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.
              Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
            29. 2010EA Loop Optional
              Repeat 14
              1. To supply the full name of an individual or organizational entity

                If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
                If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
                Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
              2. To specify identifying information

                Use the NM1 Segment for the primary identifier.
                Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter. OR Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider. If not required by this implementation guide, do not send.
              3. To specify the location of the named party

                Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
              4. To specify the geographic place of the named party

                Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
              5. 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
              6. To specify the identifying characteristics of a provider

                Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
            30. 2010EB Loop Optional
              Repeat 5
              1. To supply the full name of an individual or organizational entity

                Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
                At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
                When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops: a. ND is used to indicate the first stop b. R3 is used to indicate the second stop c. 45 is used to indicate the third stop
              2. To specify the location of the named party

              3. To specify the geographic place of the named party

            31. 2010EC Loop Optional
              Repeat 3
              1. To supply the full name of an individual or organizational entity

                Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
              2. To specify identifying information

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

            32. 2000F Loop Optional
              Repeat >1
              1. To identify dependencies among and the content of hierarchically related groups of data segments

                Required when specific services are associated with this patient event. If not required by this implementation guide, do not send.
              2. To uniquely identify a transaction to an application

                Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                This enables the requester to - uniquely identify this service line request - trace the request - match the response to the request - reference this request in any associated attachments containing additional service information related to this service line request.
                If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
                Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
                If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
              3. To specify health care services review information

                Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
              4. To specify identifying information

                This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
                Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
              5. To specify identifying information

                Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
                This is the administrative number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
              6. To specify any or all of a date, a time, or a time period

                Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.
              7. To specify the service line item detail for a health care professional

                Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.
              8. To specify the service line item detail for a health care institution

                Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
              9. To specify the service line item detail for dental work

                Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.
              10. To identify a tooth by number and, if applicable, one or more tooth surfaces

                Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.
              11. To specify the delivery pattern of health care services

                An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
                Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.
              12. To identify the type or transmission or both of paperwork or supporting information

                Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
                Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
                This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
                The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA. Refer to Section 2.5 for more information on using this PWK segment.
              13. To provide a free-form format that allows the transmission of text information

                Required when needed to transmit a message to the UMO about the service. If not required by this implementation guide, do not send.
                Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
              14. 2010F Loop Optional
                Repeat 10
                1. To supply the full name of an individual or organizational entity

                  Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
                  Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                  If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to provide services.
                2. To specify identifying information

                  Use the NM1 Segment for the primary identifier.
                  Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter. OR Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the service provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service provider. If not required by this implementation guide, do not send.
                3. To specify the location of the named party

                  Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
                4. To specify the geographic place of the named party

                  Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
                5. 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                6. To specify the identifying characteristics of a provider

                  Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
        4. 2000E Loop Optional
          Repeat 1
          1. To identify dependencies among and the content of hierarchically related groups of data segments

            Loop 2000E to provide information on the patient event associated with this health care services review.
          2. To uniquely identify a transaction to an application

            Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
            This enables the requester to - uniquely identify this patient event request - trace the request - match the response to the request - reference this request in any associated attachments containing additional patient information related to this patient event request.
            If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
            Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
          3. To specify health care services review information

            This segment identifies the type of health care services review request.
          4. To specify identifying information

            This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
            Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.
          5. To specify identifying information

            Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
          6. To specify any or all of a date, a time, or a time period

            Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
          7. To specify any or all of a date, a time, or a time period

            Required when the certification is pregnancy related. If not required by this implementation guide, do not send.
          8. To specify any or all of a date, a time, or a time period

            Required when the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
          9. To specify any or all of a date, a time, or a time period

            Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
          10. To specify any or all of a date, a time, or a time period

            Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
            If UM01 = AR use Admit Date.
          11. To specify any or all of a date, a time, or a time period

            Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
          12. To specify any or all of a date, a time, or a time period

            Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
          13. To supply information related to the delivery of health care

            Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.
          14. To specify the delivery pattern of health care services

            An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
            Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
          15. To supply information on conditions

            Required when health care services review is requesting ambulance certification. If not required by this implementation guide, do not send.
          16. To supply information on conditions

            Required when health care services review is requesting chiropractic certification. If not required by this implementation guide, do not send.
          17. To supply information on conditions

            Required when health care services is requesting durable medical equipment. If not required by this implementation guide, do not send.
          18. To supply information on conditions

            Required when health care services review is requesting oxygen therapy certification. If not required by this implementation guide, do not send.
          19. To supply information on conditions

            Required when the assessing provider has defined function limitation for the patient. If not required by this implementation guide, do not send.
          20. To supply information on conditions

            Required when the assessing provider has defined activities permitted for the patient. If not required by this implementation guide, do not send.
          21. To supply information on conditions

            Required when the patient mental status is relevant to the health care services review. If not required by this implementation guide, do not send.
          22. To supply information specific to hospital claims

            Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
          23. To supply information related to the ambulance service rendered to a patient

            Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
            When the CR1 segment is used, then Loop 2010EB is required.
          24. To supply information related to the chiropractic service rendered to a patient

            Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
          25. To supply information regarding certification of medical necessity for home oxygen therapy

            Required when requesting initial, extended, or revised certification of;home oxygen therapy. If not required by this implementation guide, do not send.
            Use the UM segment data element UM02 instead of CR501 to specify the;Certification Type Code.
            Use the HSD segment instead of CR502 to specify the treatment period.
          26. To supply information related to the certification of a home health care patient

            Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
            Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
          27. To identify the type or transmission or both of paperwork or supporting information

            Required when needed to report missing teeth on requests for dental services, or if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
            This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
            The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA. Refer to Section 2.5 for more information on using this PWK segment.
          28. To provide a free-form format that allows the transmission of text information

            Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.
            Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
          29. 2010EA Loop Optional
            Repeat 14
            1. To supply the full name of an individual or organizational entity

              If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
              If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
              Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
            2. To specify identifying information

              Use the NM1 Segment for the primary identifier.
              Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter. OR Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider. If not required by this implementation guide, do not send.
            3. To specify the location of the named party

              Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
            4. To specify the geographic place of the named party

              Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
            5. 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
            6. To specify the identifying characteristics of a provider

              Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
          30. 2010EB Loop Optional
            Repeat 5
            1. To supply the full name of an individual or organizational entity

              Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
              At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
              When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops: a. ND is used to indicate the first stop b. R3 is used to indicate the second stop c. 45 is used to indicate the third stop
            2. To specify the location of the named party

            3. To specify the geographic place of the named party

          31. 2010EC Loop Optional
            Repeat 3
            1. To supply the full name of an individual or organizational entity

              Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
            2. To specify identifying information

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

          32. 2000F Loop Optional
            Repeat >1
            1. To identify dependencies among and the content of hierarchically related groups of data segments

              Required when specific services are associated with this patient event. If not required by this implementation guide, do not send.
            2. To uniquely identify a transaction to an application

              Required when the requester needs to assign a unique trace number to the service line request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
              This enables the requester to - uniquely identify this service line request - trace the request - match the response to the request - reference this request in any associated attachments containing additional service information related to this service line request.
              If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
              Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
              If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.
            3. To specify health care services review information

              Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
            4. To specify identifying information

              This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
              Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
            5. To specify identifying information

              Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
              This is the administrative number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
            6. To specify any or all of a date, a time, or a time period

              Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.
            7. To specify the service line item detail for a health care professional

              Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.
            8. To specify the service line item detail for a health care institution

              Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
            9. To specify the service line item detail for dental work

              Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.
            10. To identify a tooth by number and, if applicable, one or more tooth surfaces

              Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.
            11. To specify the delivery pattern of health care services

              An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "Two visits per every four days for 20 days". An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
              Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.
            12. To identify the type or transmission or both of paperwork or supporting information

              Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
              Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
              This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
              The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA. Refer to Section 2.5 for more information on using this PWK segment.
            13. To provide a free-form format that allows the transmission of text information

              Required when needed to transmit a message to the UMO about the service. If not required by this implementation guide, do not send.
              Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
            14. 2010F Loop Optional
              Repeat 10
              1. To supply the full name of an individual or organizational entity

                Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
                Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to provide services.
              2. To specify identifying information

                Use the NM1 Segment for the primary identifier.
                Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter. OR Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the service provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service provider. If not required by this implementation guide, do not send.
              3. To specify the location of the named party

                Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
              4. To specify the geographic place of the named party

                Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
              5. 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 telephone 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 needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
              6. To specify the identifying characteristics of a provider

                Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
  2. To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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