EDI 278 X215 - Health Care Services Review Information - Inquiry

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

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

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

   This segment indicates the start of a Healthcare Services Review Inquiry 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 review inquiry.
   The data elements in this segment are not defined in the PAS Claim Inquiry profile because the values are hardcoded or derived.<em><br/>Implement with version: STU 1.0.0</em>

2. 0200 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

   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

   The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

Detail

1. 2000A Loop Mandatory Repeat 1

   1. 0100 · HL · Utilization Management Organization (UMO) Level · Max 1 · Mandatory

      To identify dependencies among and the content of hierarchically related groups of data segments

      This segment indicates the information source hierarchical level. For an inquiry transaction, this segment identifies the payer, HMO, or other utilization management organization that is the source of service review decision.
      The data elements in this segment are not defined in the PAS Claim Inquiry profile because the values are hardcoded or derived.<em><br/>Implement with version: STU 1.0.0</em>

   2. 2010A Loop Mandatory Repeat 1

      1. 1700 · NM1 · Utilization Management Organization (UMO) Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         This segment identifies the source of information. For an inquiry transaction this names the payer or utilization review organization responsible for the health care service review decision.
         Claim.insurer => Organization<br/>The Claim.insurer will point to a Organization in the Bundle. Locate the Organization pointed at in the Claim and use that Organization for all of the fields in the 2010A Loop<em><br/>Implement with version: STU 1.0.0</em>

   3. 2000B Loop Mandatory Repeat 1

      1. 0100 · HL · Requester Level · Max 1 · Mandatory

         To identify dependencies among and the content of hierarchically related groups of data segments

         This segment indicates the healthcare services review information receiver. For inquiry transactions, this corresponds to the identification of the entity initiating the inquiry.
         The data elements in this segment are not defined in the PAS Claim Inquiry profile because the values are hardcoded or derived.<em><br/>Implement with version: STU 1.0.0</em>

      2. 2010B Loop Mandatory Repeat 1

         1. 1700 · NM1 · Requester Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            This segment identifies the entity requesting the service review information.
            Claim.provider => Organization<br/>The Claim.provider will point to a Organization in the Bundle. Locate the Organization pointed at in the Claim and use that Organization for all of the fields in the 2010B Loop.<em><br/>Implement with version: STU 1.0.0</em>

         2. 1800 · REF · Requester Supplemental Identification · Max 9 · Optional

            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.
            The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

         3. 2000 · N3 · Requester Address · Max 1 · Optional

            To specify the location of the named party

            Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.
            Use to identify a specific location when the requester has multiple locations and authority varies based on location.
            The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

         4. 2100 · N4 · Requester City, State, ZIP Code · Max 1 · Optional

            To specify the geographic place of the named party

            Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.
            The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

         5. 2200 · PER · Requester Contact Information · Max 1 · Optional

            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 phone 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 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.
            Use this segment to identify a contact name and/or communication number for the requester.
            The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

         6. 2400 · PRV · Requester Provider Information · Max 1 · Optional

            To specify the identifying characteristics of a provider

            Required when sending a global inquiry on the status of all health care service reviews for the patient event or service type specified in Loop 2000E and/or 2000F to identify if the requester is the original requesting provider, the patient event/service provider, or primary care provider of record for the patient(s) or when the requester needs to indicate the inquiring provider's role in the care of the patient identified in Loop 2000C or 2000D and the inquiring provider's specialty. If not required by this implementation guide, do not send.
            The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

      3. 2000C Loop Optional Repeat >1

         1. 0100 · HL · Subscriber Hierarchical Level · Max 1 · Mandatory

            To identify dependencies among and the content of hierarchically related groups of data segments

            This segment is required when inquiring on the status of authorizations for a specific patient. If not required by this implementation guide, do not send.
            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.
            A transaction submitted in real time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.
            The Subscriber Hierarchical level (Loop 2000C) is required if the inquiry concerns authorizations for a specific patient. Situational use of this segment enables the requester to create an inquiry that does not specify the name or member information for each patient. If the requester omits this loop on the inquiry, the requester can inquire on the status of all the health care services review requests for which the provider is the original requesting provider, the patient event/service provider, or primary care provider of record for the patient(s). For the UMO to respond to this type of inquiry, the UMO must provide other methods of access to authorizations on file in addition to access by member ID. This guide does not require UMOs to support this level of inquiry. Support at this level is at the discretion of the UMO. The UMO must authenticate that the entity initiating the inquiry has a relationship with this patient that authorizes the requester to receive this information.
            Patient Event Loop 2000E must be valued if Loop 2000C is not valued.
            Required segments in this loop are required only when this loop is used.
            The data elements in this segment are not defined in the PAS Claim Inquiry profile because the values are hardcoded or derived.<em><br/>Implement with version: STU 1.0.0</em>

         2. 0200 · TRN · Subscriber Trace Number · Max 2 · Optional

            To uniquely identify a transaction to an application

            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 inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
            Required when the subscriber is the patient and the requester needs to assign a unique trace number to track this inquiry at the patient level. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
            The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.1.0</em>

         3. 2010C Loop Mandatory Repeat 1

            1. 1700 · NM1 · Subscriber Name · Max 1 · Mandatory

               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 Identifying the Patient in Section 1.12.2 for specific information on how to identify an individual to a UMO.
               Claim.insurance[0].coverage => Coverage.subscriber => Patient<br/>Locate the Coverage Resource in the Bundle that is referenced from the Claim.insurance[0].coverage. Then locate the Patient Resource in the Bundle referenced in the Coverage.subscriber attribute. Use the Patient Resource for all of the segments of the 2010C Loop<em><br/>Implement with version: STU 1.0.0</em>

            2. 1800 · REF · Subscriber Supplemental Identification · Max 9 · Optional

               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.
               The NM1 segment identifies the member using the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number 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 it is 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 must return the same value in this segment on the response.
               The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

            3. 2500 · DMG · Subscriber Demographic Information · Max 1 · Optional

               To supply demographic information

               Required when birth date is needed to identify the subscriber/patient. If not required by this implementation guide, do not send.
               Refer to Identifying the Patient in Section 1.12.2 for specific information on how to identify an individual to a UMO.
               The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

         4. 2000D Loop Optional Repeat >1

            1. 0100 · HL · Dependent Hierarchical Level · Max 1 · Mandatory

               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.
               This loop is required when inquiring on the status of authorizations for a specific patient who 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.
               A transaction submitted in real time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.
               The 2000D is only created when the patient is not the subscriber. Create a 2000D when Coverage referenced by Claim.insurance[0].coverage has Coverage.relationship.coding[0].code NOT equal 'self'<em><br/>Implement with version: STU 1.0.0</em>

            2. 0200 · TRN · Dependent Trace Number · Max 2 · Optional

               To uniquely identify a transaction to an application

               Required when the requester needs to assign a unique trace number to this inquiry at the patient level. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
               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 inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
               The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.1.0</em>

            3. 2010D Loop Mandatory Repeat 1

               1. 1700 · NM1 · Dependent Name · Max 1 · Mandatory

                  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.
                  Claim.patient => Patient<br/>Locate the Patient Resource in the Bundle referenced in the Claim.patient attribute. Use the Patient Resource for all of the segments of the 2010D Loop<em><br/>Implement with version: STU 1.0.0</em>

               2. 1800 · REF · Dependent Supplemental Identification · Max 3 · Optional

                  To specify identifying information

                  Required when used by the requester to identify the dependent to the UMO. If not required by this implementation guide, do not send.
                  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 must return the same value in this segment on the response.
                  The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

               3. 2500 · DMG · Dependent Demographic Information · Max 1 · Optional

                  To supply demographic information

                  Refer to Identifying the Patient in Section 1.12.2 for specific information on how to identify an individual to a UMO.
                  Required when birth date is needed to identify the dependent. If not required by this implementation guide, do not send.
                  The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

            4. 2000E Loop Optional Repeat >1

               1. 0100 · HL · Patient Event Level · Max 1 · Mandatory

                  To identify dependencies among and the content of hierarchically related groups of data segments

                  This loop is required when (1) this is a global inquiry and the Patient loop (2000C or 2000D) is not valued, or when (2) the requester wants to limit the inquiry to service reviews for a specific patient event or patient event provider associated with the patient identified, or when (3) this is a patient inquiry and the Service loop (2000F) is not valued. If not required by this implementation guide, do not send.
                  The Patient Event level enables you to further qualify your inquiry. Use this loop to identify an existing patient event level authorization associated with this inquiry.
                  When you use this loop on the inquiry, you limit the range of authorizations that meet the specifications entered. Use of this loop also ensures that the response from the UMO contains only those authorizations that meet the criteria you provided.
                  This segment is required if this loop is used.
                  A transaction submitted in real time mode can contain a maximum of one global inquiry. A transaction submitted in batch mode can contain a maximum of five global inquiries. Refer to section 1.4.1 for a description of global inquiry.
                  Used on PAS Claim Inquiry profile on FHIR Claim this segment is required for X12 submission and the values provided are used to populate the segment correctly.<em><br/>Implement with version: STU 1.0.0</em>

               2. 0200 · TRN · Patient Event Tracking Number · Max 2 · Optional

                  To uniquely identify a transaction to an application

                  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.
                  Required when the requester needs to assign a unique trace number to track this inquiry at the Patient Event level. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                  Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
                  The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

               3. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                  To specify health care services review information

                  Required when the requester wants to identify the request category, certification type code, service type, or service location of health care service review of the inquiry. If not required by this implementation guide, do not send.
                  Value this segment if you want to limit the inquiry to only referrals, or admission certifications, or health care service certifications.
                  The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

               4. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                  To specify the outcome of a health care services review

                  Required when the requester needs to limit the inquiry to only those health care service reviews on file at the UMO with a specific status. If not required by this implementation guide, do not send.
                  Use of HCR01 (action code) to limit the responses to only those authorizations that match a specific action/status may omit authorizations for which the status has changed. For example, an inquiry on all health care services reviews with a pended status will not return information on a review that has moved from a pended to a final status.
                  The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

               5. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                  To specify identifying information

                  This is the certification number previously assigned by the UMO to the original service review outcome associated with this inquiry. This is not the trace number assigned by the requester.
                  If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.
                  Required when inquiring on a previously authorized health care service review or on authorizations associated with a previously authorized health care service review and the authorization number previously assigned by the UMO is known. If not required by this implementation guide, do not send.
                  Not Used on PAS Claim Inquiry profile on FHIR Claim<em><br/>Implement with version: STU 1.0.0</em>

               6. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                  To specify identifying information

                  Required when inquiring on 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.
                  Not Used on PAS Claim Inquiry profile on FHIR Claim<em><br/>Implement with version: STU 1.0.0</em>

               7. 0700 · DTP · Accident Date · Max 1 · Optional

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

                  Required when the requester needs to limit the inquiry to authorizations for patient events associated with a specific accident date, or when this is a global inquiry and none of the other DTP segments in this loop are valued. If not required by this implementation guide, do not send.
                  A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                  The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

               8. 0700 · DTP · Event Date · Max 1 · Optional

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

                  If UM01 = AR use Admit Date.
                  A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                  Required when the requester needs to limit the inquiry to service reviews for patient events scheduled for a specific proposed or actual patient event date or date range. If not required by this implementation guide, do not send.
                  An Event Date DTP segment is created when the Claim has a supportingInfo attribute for a PatientEvent determined by:<br/>supportingInfo[n].category.coding[0].system set to 'http://hl7.org/fhir/us/<wbr> davinci-pas/<wbr> CodeSystem-PASSupportingInfoType'<br/>and<br/>supportingInfo[n].category .coding[0].code set to 'patientEvent'<em><br/>Implement with version: STU 1.0.0</em>

               9. 0700 · DTP · Admission Date · Max 1 · Optional

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

                  Use in conjunction with UM01 = "AR" (admission review) to limit the inquiry to patient events associated with requests for admission to a facility.
                  A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                  Required when the requester needs to limit the inquiry to health care service reviews for admission to a facility for a specific proposed or actual admission date. If not required by this implementation guide, do not send.
                  An Admission Date DTP segment is created when the Claim has a supportingInfo attribute for a AdmissionDates determined by:<br/>supportingInfo[n].category.coding[0].system set to 'http://hl7.org/fhir/us/davinci-pas/CodeSystem-PASSupportingInfoType' <br/>and <br/>supportingInfo[n].category.coding[0].code set to 'admissionDates'<br/>The date format in FHIR for this element is YYYY-MM-DD and will need to be converted.<br/><em><br/>Implement with version: STU 1.1.0</em>

               10. 0700 · DTP · Discharge Date · Max 1 · Optional

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

                   Required when the requester needs to limit the inquiry to admission reviews (UM01 = "AR") with an associated proposed or actual date of discharge. If not required by this implementation guide, do not send.
                   A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                   An Discharge Date DTP segment is created when the Claim has a supportingInfo attribute for a AdmissionReviewEnd determined by:<br/>supportingInfo[n].category.coding[0].system set to 'http://hl7.org/fhir/us/davinci-pas/CodeSystem-PASSupportingInfoType' <br/>and <br/>supportingInfo[n].category.coding[0].code set to 'admissionReviewEnd'<br/>The date format in FHIR for this element is CCYY-MM-DD and will need to be converted.<br/><em><br/>Implement with version: STU 1.1.0</em>

               11. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                   A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                   Required when the requester needs to limit the inquiry to those authorizations issued on a specific date or within a specific date range. If not required by this implementation guide, do not send.
                   A DTP (Certification Issue Date) segment is created in the 2000E loop when Claim.item[0].productOrServiceCode.coding[0].code is No Value<em><br/>Implement with version: STU 1.0.0</em>

               12. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                   A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                   Required when the requester needs to limit the inquiry to authorizations that expire on or by a specific date or within a specific date range. If not required by this implementation guide, do not send.
                   A DTP (Certification Expiration Date) segment is created in the 2000E loop when Claim.item[0].productOrServiceCode.coding[0].code is No Value<em><br/>Implement with version: STU 1.0.0</em>

               13. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                   Required when the requester needs to limit the inquiry to authorizations that expire on or by a specific date or within a specific date range. If not required by this implementation guide, do not send.
                   A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                   A DTP (Certification Effective Date) segment is created in the 2000E loop when Claim.item[0].productOrServiceCode.coding[0].code is No Value<em><br/>Implement with version: STU 1.0.0</em>

               14. 0700 · DTP · Health Care Services Review Request Date · Max 1 · Optional

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

                   Required when the requester needs to limit the inquiry to service reviews requested on a specific date or date range, or when this is a global inquiry and none of the other DTP segments in this loop are valued and the Service Date DTP in Loop 2000F is not valued. If not required by this implementation guide, do not send.
                   A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.
                   The date when the requester initiated the health care services review request might not be consistent with the date when the UMO received the health care services review request. Use of this segment implies that only those certifications that match on this value are returned by the UMO.
                   The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

               15. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                   To supply information related to the delivery of health care

                   Required when the requester needs to limit the inquiry to authorizations related to a specific diagnosis associated with a single episode of care. If not required by this implementation guide, do not send.
                   The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

               16. 2010EA Loop Optional Repeat 14

                   1. 1700 · NM1 · Patient Event Provider Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when the requester needs to limit the inquiry to authorizations for patient event providers other than or in addition to the provider identified in the Loop 2010B, or limit the inquiry to authorizations for a specialty entity for this patient event. If not required by this implementation guide, do not send.
                      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.
                      The data elements in this segment are defined in the PAS Claim profile, see the FHIR Mapping instructions for each data element below.<br/>Claim.careTeam[n].provider can point to either an Organization or Practitioner Resource.<br/>For each Claim.careTeam[n].extension(careTeamClaimScope).valueBoolean = true (maximum of 14).<br/><em><br/>Implement with version: STU 1.1.0</em>

                   2. 1800 · REF · Patient Event Provider Supplemental Information · Max 8 · Optional

                      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 Patient Event 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.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<br/>If Organization.identifier[n].type.coding[0].code is equal to 'SL' (State License Number), do not create this REF Segment.<br/><em><br/>Implement with version: STU 1.1.0</em>

                   3. 2000 · N3 · Patient Event Provider Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when limiting the inquiry to authorizations for a patient event location and the patient event provider has multiple locations to identify the specific location. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   4. 2100 · N4 · Patient Event Provider City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when limiting the inquiry to authorizations for a patient event location and the patient event provider has multiple locations to identify the specific location. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   5. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      To specify the identifying characteristics of a provider

                      Required when inquiring on authorizations for services of a specialty entity to indicate the specialty. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

               17. 2000F Loop Optional Repeat >1

                   1. 0100 · HL · Service Level · Max 1 · Mandatory

                      To identify dependencies among and the content of hierarchically related groups of data segments

                      Required when the Patient Event loop is not valued or when inquiring on authorizations for specific services or procedures. If not required, by this implementation guide, do not send.
                      This segment is required if this loop is used.
                      Claim.item[n]<br/>Each occurrence of Claim.item will have a corresponding 2000F occurrence except when the item[0].productOrServiceCode.coding[0].code is No Value (there should be only a single Claim.item in this situation and no 2000F Loop will be created)<em><br/>Implement with version: STU 1.0.0</em>

                   2. 0200 · TRN · Service Trace Number · Max 2 · Optional

                      To uniquely identify a transaction to an application

                      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.
                      Required when the requester needs to track this inquiry at the Service level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
                      Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
                      Create one TRN segment for each itemTraceNumber extension up to three (3) in the PAS Claim Inquiry.<br/><em><br/>Implement with version: STU 1.1.0</em>

                   3. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                      To specify health care services review information

                      Required when the requester wants to limit the inquiry to a specific service type or procedure and the associated request category, certification type code, service type, or service location differs from the information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.
                      Value this segment if you want to limit the inquiry to only referrals or only health care service certifications.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   4. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                      To specify the outcome of a health care services review

                      Use of HCR01 (action code) to limit the responses to only those authorizations that match a specific action/status may omit authorizations for which the status has changed. For example, an inquiry on all health care services reviews with a pended status will not return information on a review that has moved from a pended to a final status.
                      Required when the requester needs to limit the inquiry to only those authorizations for a service with a specific status such as "term expired" and that status is different from the value in HCR01 at the Patient Event Level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   5. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                      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 inquiring on a previously authorized health care service review and the authorization number assigned by the UMO is known and different from the number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
                      If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   6. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                      To specify identifying information

                      This is the administrative number assigned by the UMO to the original service review outcome. This is not the trace number assigned by the requester.
                      Required when inquiring on a previous health care services review request for which the UMO has returned a response that contained an administrative reference number at the Service level for this service (Loop 2000F REF segment where REF01 = NT) and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   7. 0700 · DTP · Service Date · Max 1 · Optional

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

                      Required when limiting the inquiry to those authorizations for service for a specific service date or service date range. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   8. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                      Required when limiting the inquiry to authorizations for a service issued on a specific date or within a specific date range that is different from the certification date(s) specified in the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   9. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                      Required when limiting the inquiry to authorizations for a service that expire on or by a specific date or within a specific date range and the date(s) differ from the certification expiration date(s) specified at the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.
                      The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   10. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                       Required when limiting the inquiry to those certifications that are effective for a specific date or date range and the effective date(s) differ from the effective date(s) specified at the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.
                       The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                   11. 0810 · SV1 · Professional Service · Max 1 · Optional

                       To specify the service line item detail for a health care professional

                       Required when inquiring on authorizations for a specific professional service. If not required by this implementation guide, do not send.
                       If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.
                       The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<br/>If Claim.type.coding[0].code = 'professional' then populate the SV1 segment otherwise do not populate the elements.<em><br/>Implement with version: STU 1.0.0</em>

                   12. 0820 · SV2 · Institutional Service · Max 1 · Optional

                       To specify the service line item detail for a health care institution

                       Required when inquiring on authorizations for a specific Institutional Service or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.
                       If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.
                       The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<br/>If Claim.type.coding[0].code = 'institutional' then populate the SV1 segment otherwise do not populate the elements.<br/><em><br/>Implement with version: STU 1.0.0</em>

                   13. 0830 · SV3 · Dental Service · Max 1 · Optional

                       To specify the service line item detail for dental work

                       Required when inquiring on authorizations for a specific Dental Service. If not required by this implementation guide, do not send.
                       If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.
                       The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

                   14. 0840 · TOO · Tooth Information · Max 1 · Optional

                       To identify a tooth by number and, if applicable, one or more tooth surfaces

                       Required when inquiring on authorizations for a specific tooth number and/or tooth surface related to this procedure line. If not required by this implementation guide, do not send.
                       The data elements in this segment are not defined in the PAS Claim Inquiry profile.<em><br/>Implement with version: STU 1.0.0</em>

                   15. 2010F Loop Optional Repeat 10

                       1. 1700 · NM1 · Service Provider Name · Max 1 · Mandatory

                          To supply the full name of an individual or organizational entity

                          This segment is required if Loop 2010F is used.
                          Required when inquiring on authorizations for a specific service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010E (Patient Event Provider Name). If not required by this implementation guide, do not send.
                          The data elements in this segment are defined in the PAS Claim profile, see the FHIR Mapping instructions for each data element below.<br/>Claim.careTeam[n].provider => Practitioner | Organization<br/>Where Claim.careTeam[n].sequence = Claim.item[n].careTeamSequence[0..9] (create for the 1st 10 occurrences only)<em><br/>Implement with version: STU 1.1.0</em>

                       2. 1800 · REF · Service Provider Supplemental Identification · Max 8 · Optional

                          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 Service 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.
                          The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<br/>If Organization.identifier[n].type.coding[0].code is equal to 'SL' (State License Number), do not create this REF Segment.<br/><em><br/>Implement with version: STU 1.1.0</em>

                       3. 2000 · N3 · Service Provider Address · Max 1 · Optional

                          To specify the location of the named party

                          Required when limiting the inquiry to authorizations for services at a specific provider location and the service provider has multiple locations. If not required by this implementation guide, do not send.
                          The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                       4. 2100 · N4 · Service Provider City, State, ZIP Code · Max 1 · Optional

                          To specify the geographic place of the named party

                          Required when limiting the inquiry to authorizations for services at a specific provider location and the service provider has multiple locations. If not required by this implementation guide, do not send.
                          The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

                       5. 2400 · PRV · Service Provider Information · Max 1 · Optional

                          To specify the identifying characteristics of a provider

                          Required when limiting the inquiry to authorizations for the services of a specialty entity to indicate the specialty. If not required by this implementation guide, do not send.
                          The data elements in this segment are defined in the PAS Claim Inquiry profile, see the FHIR Mapping instructions for each data element below.<em><br/>Implement with version: STU 1.0.0</em>

2. 2800 · SE · 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)

   The data elements in this segment are not defined in the PAS Claim Inquiry profile because the values are hardcoded or derived.<em><br/>Implement with version: STU 1.0.0</em>