EDI 278 X215 - Health Care Services Review Information - Response

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 health care services review inquiry response transaction set with all the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management inquiry response.

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

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. The information source corresponds to the payer, HMO, or other utilization management organization that is the source of the health care services review decision/response.

   2. 0300 · AAA · Request Validation · Max 9 · Optional

      To specify the validity of the request and indicate follow-up action authorized

      Required when the request cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS); or when the entity responsible for forwarding the inquiry to the information source (identified in Loop 2010A) is unable to process the transaction at the current time. If not required by this implementation guide, do not send.

   3. 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. In the case of a response to a inquiry transaction, the information source would normally be the payer or utilization review organization that stores the decision regarding the original health care service review request.

      2. 2200 · PER · Utilization Management Organization (UMO) Contact Information · Max 1 · Optional

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

         Use this segment to identify a contact name and/or communication number for the UMO.
         Required when the requester must direct requests for follow-up to a specific UMO contact, email, facsimile, or telephone. 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 immedidately after the telephone number.

      3. 2300 · AAA · Utilization Management Organization (UMO) Request Validation · Max 9 · Optional

         To specify the validity of the request and indicate follow-up action authorized

         Required when the request cannot be processed at the system or application level based on the Utilization Management Organization (information source) identified in Loop 2010A. If not required by this implementation guide, do not send.

   4. 2000B Loop Optional Repeat 1

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

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

         Required when the UMO system processed any of the information contained in Loop 2000B of the inquiry transaction. If not required by this implementation guide, do not send.
         If the UMO system was unable to process any data beyond Loop 2000A, Loop 2000B is not used.
         This segment indicates the health care services review information receiver. For responses to inquiry transactions, this segment corresponds to the identification of the provider who initiated the inquiry.

      2. 2010B Loop Mandatory Repeat 2

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

            To supply the full name of an individual or organizational entity

            This loop identifies the receiver of information.

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

            To specify identifying information

            Required prior to the mandated NPI implementation date when the requester is a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the Health Care Provider. OR Required when the requester is not a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the requester. OR Required prior to the mandated NPI implementation date when an identifier other than an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the requester. If not required by this implementation guide, do not send.

         3. 2300 · AAA · Requester Request Validation · Max 9 · Optional

            To specify the validity of the request and indicate follow-up action authorized

            Use this segment to convey rejection information regarding the entity that initiated the inquiry transaction.
            Required when the inquiry is not valid or no authorizations on file match the inquiry criteria specified at this level. If not required by this implementation guide, do not send.

         4. 2400 · PRV · Requester Provider Information · Max 1 · Optional

            To specify the identifying characteristics of a provider

            Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.

      3. 2000C Loop Optional Repeat >1

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

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

            If the UMO system processed any of the information contained in Loop 2000C of the request, the UMO system must return a response or error response containing this HL. If the UMO system was unable to process any data beyond Loop 2000B of the request, then Loop 2000C is not required.
            This segment corresponds to the identification of the subscriber or individual insured member.
            Required when this is a response to a patient inquiry and the UMO system processed any of the information contained in Loop 2000C of the inquiry, or when this is a response to a global inquiry and authorizations were found in the UMO system that match the inquiry search criteria. If not required by this implementation guide, do not send.

         2. 0200 · TRN · Subscriber Trace Number · Max 3 · Optional

            To uniquely identify a transaction to an application

            Required when this loop is returned and the inquiry contained a tracking number at this level or when the UMO or clearinghouse assigns a trace number at the Patient level in the response for tracking purposes. If not required by this implementation guide, do not send.
            Any trace numbers provided at this level on the inquiry must be returned by the UMO at this level of the 278 inquiry response.
            If the 278 inquiry transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 inquiry response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the inquiry response transaction.
            If the 278 inquiry passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive an inquiry response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.

         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 identifies the subscriber.

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

               To specify identifying information

               Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is provided in the NM1 segment as a Member Identification Number when it is the primary number by which the UMO knows the member (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.
               Required when a supplementary identifier is used by the UMO to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the inquiry. If not required by this implementation guide, do not send.

            3. 2000 · N3 · Subscriber Mailing Address · Max 1 · Optional

               To specify the location of the named party

               Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

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

               To specify the geographic place of the named party

               Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

            5. 2300 · AAA · Subscriber Request Validation · Max 9 · Optional

               To specify the validity of the request and indicate follow-up action authorized

               Required when the inquiry is not valid or no authorizations on file match the inquiry criteria specified at this level. If not required by this implementation guide, do not send.

            6. 2500 · DMG · Subscriber Demographic Information · Max 1 · Optional

               To supply demographic information

               Required when used by the UMO to identify the subscriber/patient. If not required by this implementation guide, do not send.

         4. 2000D Loop Optional Repeat >1

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

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

               Required segments in this loop are required only when this loop is used. If the UMO system was unable to process any data beyond Loop 2000C of the request, Loop 2000D is not required.
               Required when this is a response to a patient inquiry and the UMO system processed any of the information contained in Loop 2000D of the inquiry, or when this is a response to a global inquiry and any authorizations that match the inquiry search criteria were found where the patients are dependents and do not have a unique member ID. If not required by this implementation guide, do not send.

            2. 0200 · TRN · Dependent Trace Number · Max 3 · Optional

               To uniquely identify a transaction to an application

               Required when this loop is returned and the inquiry contained a tracking number at this level or when the UMO or clearinghouse assigns a trace number at the Patient level in the response for tracking purposes. If not required by this implementation guide, do not send.
               Any trace numbers provided at this level on the inquiry must be returned by the UMO at this level of the 278 inquiry response.
               If the 278 inquiry transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 inquiry response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the inquiry response transaction.
               If the 278 inquiry passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive an inquiry response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.

            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.
                  NM108 and NM109 are situational on the response but Not Used on the inquiry. This enables the UMO to return a unique member ID for the dependent that was not known to the requester. Normally, if the dependent has a unique member ID, Loop 2000D is not used.

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

                  To specify identifying information

                  Required when a supplementary identifier is used by the UMO to identify the Dependent or when REF01 = "EJ" (Patient Account Number) is valued on the inquiry. If not required by this implementation guide, do not send.

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

                  To specify the location of the named party

                  Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

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

                  To specify the geographic place of the named party

                  Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.

               5. 2300 · AAA · Dependent Request Validation · Max 9 · Optional

                  To specify the validity of the request and indicate follow-up action authorized

                  Required when the inquiry is not valid or no authorizations on file match the inquiry criteria specified at this level. If not required by this implementation guide, do not send.

               6. 2500 · DMG · Dependent Demographic Information · Max 1 · Optional

                  To supply demographic information

                  Required when used by the UMO to identify the patient. If not required by this implementation guide, do not send.

            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

                  Required when the UMO system processed any of the information contained in Loop 2000E of the inquiry, or when the response returns patient event authorization information. If not required by this implementation guide, do not send.
                  If the UMO was unable to process any data beyond Loop 2000C or Loop 2000D of the inquiry this loop and any subordinate loops are not required.
                  This loop is required if certifications are found that match the criteria specified in the inquiry.
                  Use this segment to identify the patient event(s) and to convey the review outcome related to the patient event(s).
                  Use multiple occurrences of this loop if more than one patient event certification exists for this patient.
                  Required segments in this loop are required only when this loop is used.

               2. 0200 · TRN · Patient Event Tracking Number · Max 3 · Optional

                  To uniquely identify a transaction to an application

                  Any trace numbers provided at this level on the inquiry must be returned by the UMO at this level of the 278 inquiry response.
                  If the 278 inquiry transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
                  If the 278 inquiry passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
                  Required when this loop is returned and the inquiry contained a tracking number at this level, or if the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking purposes. If not required by this implementation guide, do not send.

               3. 0300 · AAA · Patient Event Request Validation · Max 9 · Optional

                  To specify the validity of the request and indicate follow-up action authorized

                  Use this AAA segment to identify the reasons why the inquiry could not be processed based on the data at this level of the inquiry.
                  Required when the inquiry is not valid at this level to indicate the data condition that prohibits processing of the inquiry, or when the UMO has no authorizations on file that match the inquiry criteria specified at the Patient Event level of the inquiry. If not required by this implementation guide, do not send.

               4. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                  To specify health care services review information

                  Required when the response returns information on health care service reviews on file to identify the request category, service type, or service location associated with the health care service review. If not required by this implementation guide, do not send.

               5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                  To specify the outcome of a health care services review

                  Required when returning authorization information that matches the inquiry and the UMO has reviewed the original request at this level, to indicate the status of the review. If not required by this implementation guide, do not send.
                  If the UMO was unable to locate authorizations due to missing or invalid application data at this level of the inquiry, the UMO must return a 278 response containing a AAA segment at this level.
                  If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in loop 2000E.
                  If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

               6. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                  To specify identifying information

                  Required when valued on the inquiry and the UMO does not have certification information on file that matches this previously assigned authorization number or when the authorization number submitted on the inquiry has been superseded. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                  If the requester valued this segment on the inquiry and the UMO has certification information on file that matches the previous certification number, the UMO must return that certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response.

               7. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                  To specify identifying information

                  Required when valued on the inquiry and the UMO does not have certification information on file that matches this previously assigned administrative reference number. If not required by this implementation, may be provided at the sender's discretion but cannot be required by the receiver.
                  If the requester valued this segment on the inquiry and the UMO has health care service review outcome information on file that matches the previous review administrative reference number, the UMO must return that outcome information in the HCR Health Care Service Review segment of the inquiry response. If the event was authorized, the UMO system must return the authorization number in HCR02.

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

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

                  Required when the UMO authorized the patient event for a specific date or date range. If not required by this implementation guide, do not send.

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

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

                  Required when the UMO authorized admission for a specific date or date range. If not required by this implementation guide, do not send.

               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 UMO authorized services or admission based on the proposed or actual discharge date. If not required by this implementation guide, do not send.

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

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

                   This is not the effective date of the authorization. This is the date when the UMO issued the authorization.
                   Required when the UMO assigned a certification issue date to this authorization. If not required by this implementation guide, do not send.

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

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

                   Required when the authorization has an expiration date to indicate the date on which the authorization expired or will expire. If not required by this implementation guide, do not send.

               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 authorization is limited by effective dates to indicate the date or date range when the certification is effective. If not required by this implementation guide, do not send.

               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 UMO limits the search by request date or request date range, or when valued on the inquiry and used by the UMO to locate authorizations. If not required by this implementation guide, do not send.

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

                   To supply information related to the delivery of health care

                   Required when valued on the inquiry and used by the UMO to search for authorizations. If not required by this implementation guide, do not send.
                   Only one diagnosis code is supported on the inquiry. Therefore, only one occurrence of the C022 composite is supported in this HI segment.

               16. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                   To specify the delivery pattern of health care services

                   Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
                   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 the UMO authorized services that have a specific pattern of delivery for the patient event. If not required by this implementation guide, do not send.

               17. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                   To supply information specific to hospital claims

                   Required when the certification is for admission (UM01 = AR) to a facility and the information is known by the UMO. If not required by this implementation guide, do not send.

               18. 1200 · CR1 · Ambulance Transport Information · Max 1 · Optional

                   To supply information related to the ambulance service rendered to a patient

                   Required when this is an authorization for specific non-emergency transport services. If not required by this implementation guide, do not send.

               19. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                   To supply information related to the chiropractic service rendered to a patient

                   Required when the authorization is for spinal manipulation services that have a specific pattern of delivery usage. If not required by this implementation guide, do not send.

               20. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

                   To supply information regarding certification of medical necessity for home oxygen therapy

                   Required when the UMO has authorized specific usage of home oxygen therapy. If not required by this implementation guide, do not send.

               21. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

                   To supply information related to the certification of a home health care patient

                   Required when the UMO has authorized a home health plan of treatment. If not required by this implementation guide, do not send.

               22. 1600 · MSG · Message Text · Max 1 · Optional

                   To provide a free-form format that allows the transmission of text information

                   Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.

               23. 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 valued on the inquiry and used by the UMO to locate authorizations, or when the UMO has authorized a specific provider or 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.

                   2. 1800 · REF · Patient Event Provider Supplemental Identification · Max 9 · Optional

                      To specify identifying information

                      Use the NM1 segment for the primary identifier.
                      Required prior to the mandated NPI implementation date when the Patient Event Provider is a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the Health Care Provider. OR Required when the Patient Event Provider is not a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the provider. OR Required prior to the mandated NPI implementation date when an identifier other than an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.

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

                      To specify the location of the named party

                      Required when the UMO authorized a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

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

                      To specify the geographic place of the named party

                      Required when the UMO authorized a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.

                   5. 2200 · PER · Patient Event Provider Contact Information · Max 1 · Optional

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

                      When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immedidately after the telephone number.
                      Required when needed to identify a contact name and/or communication 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. 2300 · AAA · Patient Event Provider Request Validation · Max 9 · Optional

                      To specify the validity of the request and indicate follow-up action authorized

                      Required when the inquiry is not valid at this level to indicate the data condition that prohibits processing of the inquiry, or when the UMO has no authorizations on file that match the inquiry criteria specified at this level of the inquiry. If not required by this implementation guide, do not send.

                   7. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      To specify the identifying characteristics of a provider

                      Required when used by the UMO to identify the provider specialty. If not required by this implementation guide, do not send.

               24. 2010EB Loop Optional Repeat 5

                   1. 1700 · NM1 · Patient Event Transport Information · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when the UMO has authorized transport services that stipulate a specific origin and destination by address. If not required by this implementation guide, do not send.

                   2. 2000 · N3 · Patient Event Transport Location Address · Max 1 · Mandatory

                      To specify the location of the named party

                   3. 2100 · N4 · Patient Event Transport Location City/State/ZIP Code · Max 1 · Mandatory

                      To specify the geographic place of the named party

               25. 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 UMO system processed any of the information contained in Loop 2000F of the inquiry, or when the response returns authorization information about specific services or procedures. If not required by this implementation guide, do not send.
                      This segment conveys review information related to specific service(s).
                      Use multiple occurrences of this loop if more than one service has been requested for this patient event.
                      Required segments in this loop are required only when this loop is used.

                   2. 0200 · TRN · Service Trace Number · Max 3 · Optional

                      To uniquely identify a transaction to an application

                      Any trace numbers provided at this level on the inquiry must be returned by the UMO at this level of the 278 inquiry response.
                      If the 278 inquiry transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
                      If the 278 inquiry passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
                      Required when this loop is returned and the inquiry contained a tracking number at this level, or if the UMO or clearinghouse assigns a trace number to this service in the response for tracking purposes. If not required by this implementation guide, do not send.

                   3. 0300 · AAA · Service Request Validation · Max 9 · Optional

                      To specify the validity of the request and indicate follow-up action authorized

                      Required when the inquiry is not valid at this level to indicate the data condition that prohibits processing of the inquiry, or when the UMO has no authorizations on file that match the inquiry criteria specified at the Service level of the inquiry. If not required by this implementation guide, do not send.
                      Use this AAA segment to identify the reasons why the inquiry could not be processed based on the data at this level of the inquiry.

                   4. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                      To specify health care services review information

                      Required when needed to identify the request category, service type, or service location for specific services and that information differs from the information returned in the Patent Event level (Loop 2000E) of this response. If not required by this implementation guide, do not send.

                   5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                      To specify the outcome of a health care services review

                      Required when the UMO has reviewed the original request at this level, and the UMO renders a decision at both the Patient Event level and at the Service level, to provide service review outcome information and an associated reference number. If not required by this implementation guide, do not send.
                      If the UMO was unable to locate authorizations due to missing or invalid application data at this level of the inquiry, the UMO must return a 278 response containing a AAA segment at this level.
                      If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.

                   6. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                      To specify identifying information

                      Required when valued on the inquiry and the UMO does not have certification information on file that matches this previously assigned authorization number or when the authorization number submitted on the inquiry has been superseded. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                      If the requester valued this segment on the inquiry and the UMO has certification information on file that matches the previous certification number, the UMO must return that certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response.

                   7. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                      To specify identifying information

                      Required when valued on the inquiry and the UMO does not have certification information on file that matches this previously assigned administrative reference number. If not required by this implementation, may be provided at the sender's discretion but cannot be required by the receiver.
                      If the requester valued this segment on the inquiry and the UMO has health care service review outcome information on file that matches the previous review administrative reference number, the UMO must return that outcome information in the HCR Health Care Service Review segment of the inquiry response. If the event was authorized, the UMO system must return the authorization number in HCR02.

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

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

                      Required when the UMO authorized the service for a specific date or date range. If not required by this implementation guide, do not send.

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

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

                      This is not the effective date of the authorization. This is the date when the UMO issued the authorization.
                      Required when the UMO assigned a certification issue date to this authorization. If not required by this implementation guide, do not send.

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

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

                       Required when the authorization has an expiration date to indicate the date on which the authorization expired or will expire. If not required by this implementation guide, do not send.

                   11. 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 authorization is limited by effective dates to indicate the date or date range when the certification is effective. If not required by this implementation guide, do not send.

                   12. 0810 · SV1 · Professional Service · Max 1 · Optional

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

                       Required when the UMO has authorized a specific professional service. If not required by this implementation guide, do not send.

                   13. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

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

                       Required when the UMO has authorized a specific institutional service. If not required by this implementation guide, do not send.
                       Use this segment to identify a specific revenue code.

                   14. 0830 · SV3 · Dental Service · Max 1 · Optional

                       To specify the service line item detail for dental work

                       Required when the UMO has authorized a specific Dental Service. If not required by this implementation guide, do not send.

                   15. 0840 · TOO · Tooth Information · Max 32 · Optional

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

                       Required when SV3 is valued and the UMO has authorized the procedure for a specific tooth number and/or tooth surface related to this procedure line. If not required by this implementation guide, do not send.

                   16. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                       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 the UMO authorized services with 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 or when identifying the number of medical services reservations remaining. If not required by this implementation guide, do not send.

                   17. 1600 · MSG · Message Text · Max 1 · Optional

                       To provide a free-form format that allows the transmission of text information

                       Required when it is necessary to send additional information about the Service which could not otherwise be codified within the 2000F Loop. If not required by this implementation guide, do not send.

                   18. 2010F Loop Optional Repeat 12

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

                          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) or to identify the specialty entity.
                          Required when the UMO authorized a specific provider or specialty entity for this service. If not required by this implementation guide, do not send.

                       2. 1800 · REF · Service Provider Supplemental Identification · Max 9 · Optional

                          To specify identifying information

                          Use the NM1 segment for the primary identifier.
                          Required prior to the mandated NPI implementation date when the Service Provider is a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the Health Care Provider. OR Required when the Service Provider is not a Health Care Provider and an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the provider. OR Required prior to the mandated NPI implementation date when an identifier other than an NPI is reported in NM109 of this loop and an additional identification number is required by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.

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

                          To specify the location of the named party

                          Required when the UMO uses the address to further identify the service provider or when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

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

                          To specify the geographic place of the named party

                          Required when the UMO uses the address to further identify the service provider or when the UMO authorizes a specific location for a service provider that has multiple locations. If not required by this implementation guide, do not send.

                       5. 2200 · PER · Service Provider Contact Information · Max 1 · Optional

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

                          When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534) 224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immedidately after the telephone number.
                          Required when needed to identify a contact name and/or communication 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. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

                          To specify the validity of the request and indicate follow-up action authorized

                          Required when the inquiry is not valid at this level to indicate the data condition that prohibits processing of the inquiry, or when the UMO has no authorizations on file that match the inquiry criteria specified at the this level of the inquiry. If not required by this implementation guide, do not send.

                       7. 2400 · PRV · Service Provider Information · Max 1 · Optional

                          To specify the identifying characteristics of a provider

                          Required when used by the UMO to identify the provider specialty. If not required by this implementation guide, do not send.

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)