EDI 278 X216 - Health Care Services Review Information - Acknowledgment
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
- 0100Transaction Set HeaderMandatoryMax 1
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 notification acknowledgment response transaction set with all the supporting information. This transaction set is the electronic equivalent of a phone, fax, or paper-based receipt acknowledgment. - 0200Beginning of Hierarchical TransactionMandatoryMax 1
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
- 2000A Loop MandatoryRepeat 1
- 0100Information Source LevelMandatoryMax 1
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 source of the notification or information copy. - 0300Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send. - 2010A Loop MandatoryRepeat 2
- 1700Information Source NameMandatoryMax 1
To supply the full name of an individual or organizational entity
This NM1 loop identifies the notification sender. In most cases, the sender is the same entity as the information source. The information source is the entity that determined the outcome of a health services review or the owner of the information. If the sender is not the same entity as the information source, use the first NM1 loop to identify the information sender and the second NM1 loop to identify the information source.The second NM1 loop is required when the sender is not the same entity as the information source. If not required by this implementation guide, do not send. - 1800Information Source Supplemental IdentificationOptionalMax 9
To specify identifying information
Required when valued on the notification and used by the receiver to identify the information source or sender. If not required by this implementation guide, do not send. - 2300Information Source ValidationOptionalMax 9
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 a notification or information copy transaction.Required when the notification is not valid at this level. If not required by this implementation guide, do not send. - 2400Information Source Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
Required when used by the information receiver to identify the information source. If not required by this implementation guide, do not send.
- 1700Information Source NameMandatoryMax 1
- 2000B Loop OptionalRepeat 1
- 0100Information Receiver LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
This segment indicates the health care services review information receiver. The information receiver is the entity that received the notification.Required when this loop is used. If the information receiver's system processed any of the information contained in Loop 2000B of the notification, the acknowledgment must return Loop 2000B. If the information receiver's system was unable to process any data beyond Loop 2000A of the notification, then Loop 2000B is not used. If not required by this implementation guide, do not send. - 2010B Loop MandatoryRepeat 1
- 1700Information Receiver NameMandatoryMax 1
To supply the full name of an individual or organizational entity
This NM1 loop identifies the notification receiver. - 2200Information Receiver Contact InformationOptionalMax 1
To identify a person or office to whom administrative communications should be directed
When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.Required when the information source must direct requests for follow-up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send. - 2300Information Receiver Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Use this AAA segment to report the reasons why the information receiver cannot receive the notification at a system or application level based on the information source identified in Loop 2010A.Required when the notification is not valid at this level. If not required by this implementation guide, do not send.
- 1700Information Receiver NameMandatoryMax 1
- 2000C Loop OptionalRepeat 1
- 0100Subscriber LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
This segment indicates the subscriber hierarchical level. The subscriber could also be the patient. If the subscriber is the patient, then the dependent hierarchical level (Loop 2000D) is not used.Required when the information receiver has detected no errors at the parent level (Loop 2000B) of the notification. If not required by this implementation guide, do not send. - 0200Subscriber Trace NumberOptionalMax 3
To uniquely identify a transaction to an application
Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.If the 278 notification 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 acknowledgment 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 acknowledgment transaction.If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver'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 information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send. - 0300Subscriber Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Use this AAA segment to identify the reasons why the notification could not be received based on the contents of the HI Subscriber Diagnosis segment or the DTP date segments in Loop 2000C of the notification.Required when the notification is not valid at this level. If not required by this implementation guide, do not send. - 0600Notification Receipt NumberOptionalMax 1
To specify identifying information
Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send. - 2010C Loop MandatoryRepeat 1
- 1700Subscriber NameMandatoryMax 1
To supply the full name of an individual or organizational entity
- 1800Subscriber Supplemental IdentificationOptionalMax 9
To specify identifying information
Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send. - 2300Subscriber Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level. If not required by this implementation guide, do not send. - 2500Subscriber Demographic InformationOptionalMax 1
To supply demographic information
Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send. - 2600Subscriber RelationshipOptionalMax 1
To provide benefit information on insured entities
Required when the subscriber's role in the military is used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send.
- 1700Subscriber NameMandatoryMax 1
- 2000D Loop OptionalRepeat 1
- 0100Dependent LevelMandatoryMax 1
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.Required when valued on the notification and the information receiver has detected no errors at the parent level (Loop 2000C) of the notification. If not required by this implementation guide, do not send. - 0200Dependent Trace NumberOptionalMax 3
To uniquely identify a transaction to an application
Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.If the 278 notification 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 acknowledgment 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 notification in the 278 acknowledgment response transaction.Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver'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 information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number. - 0300Dependent Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Use this AAA segment to identify the reasons why the notification could not be processed based on the contents of the HI Dependent Diagnosis Segment or the DTP date segments in Loop 2000D of the notification.Required when the notification is not valid at this level. If not required by this implementation guide, do not send. - 0600Notification Receipt NumberOptionalMax 1
To specify identifying information
Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send. - 2010D Loop MandatoryRepeat 1
- 1700Dependent NameMandatoryMax 1
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 acknowledgment but Not Used on the notification. This enables the information receiver (UMO for example) to return a unique member ID for the dependent that was not known to the information source at the time of the review. Normally, if the dependent has a unique member ID, Loop 2000D is not used. - 1800Dependent Supplemental IdentificationOptionalMax 3
To specify identifying information
Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send. - 2300Dependent Notification ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level. If not required by this implementation guide, do not send. - 2500Dependent Demographic InformationOptionalMax 1
To supply demographic information
Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the patient. If not required by this implementation guide, do not send. - 2600Dependent RelationshipOptionalMax 1
To provide benefit information on insured entities
Required when valued on the notification and used by the information receiver to identify the patient. If not required by this implementation guide, do not send.
- 1700Dependent NameMandatoryMax 1
- 2000E Loop OptionalRepeat >1
- 0100Patient Event LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
Required when the information receiver has detected errors at the patient event or subsequent service levels of the notification or when a receipt number is assigned at the event level of a received notification. If not required by this implementation guide, do not send.Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only. - 0200Patient Event Tracking NumberOptionalMax 3
To uniquely identify a transaction to an application
Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.If the 278 notification transaction passed 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 acknowledgment 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 acknowledgment transaction.If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source'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 acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number. - 0300Patient Event Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level. If not required by this implementation guide do not send. - 0400Health Care Services Review InformationMandatoryMax 1
To specify health care services review information
Required to identify the type of health care services review notification to which this acknowledgment pertains. - 0500Health Care Services ReviewOptionalMax 1
To specify the outcome of a health care services review
Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.If the acknowledgment 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. - 0600Administrative Reference NumberOptionalMax 1
To specify identifying information
Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver. - 0600Previous Review Authorization NumberOptionalMax 1
To specify identifying information
Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send. - 0700Event DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the valid date(s) during which this event can occur. If not required, do not send.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Admission DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the proposed or actual date of admission.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Discharge DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the proposed or actual date of discharge from a facility.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Issue DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the date when the certification was issued.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Expiration DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Effective DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0800Patient DiagnosisOptionalMax 1
To supply information related to the delivery of health care
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.This segment is used to hold the event level diagnosis code information that was part of the notification transaction. - 2010E Loop OptionalRepeat 12
- 1700Patient Event Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error. - 1800Patient Event Provider Supplemental IdentificationOptionalMax 7
To specify identifying information
Use the NM1 segment for the primary identifier.Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send. - 2300Patient Event Provider Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send. - 2400Patient Event Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
- 1700Patient Event Provider NameMandatoryMax 1
- 2000F Loop OptionalRepeat >1
- 0100Service LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
Required when the information receiver has detected errors at this level of the notification, or assigns a receipt number to each service level on the notification that it receives. If not required by this implementation guide, do not send. - 0200Service Trace NumberOptionalMax 3
To uniquely identify a transaction to an application
Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.If the 278 notification transaction passed 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 acknowledgment 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 acknowledgment transaction.If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source'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 acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number. - 0300Service Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send. - 0400Health Care Services Review InformationOptionalMax 1
To specify health care services review information
Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send. - 0500Health Care Services ReviewOptionalMax 1
To specify the outcome of a health care services review
Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification. - 0600Previous Review Authorization NumberOptionalMax 1
To specify identifying information
Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send. - 0600Administrative Reference NumberOptionalMax 1
To specify identifying information
Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver. - 0700Service DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Issue DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Expiration DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Effective DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0810Professional ServiceOptionalMax 1
To specify the service line item detail for a health care professional
Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0820Institutional Service LineOptionalMax 1
To specify the service line item detail for a health care institution
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0830Dental ServiceOptionalMax 1
To specify the service line item detail for dental work
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0840Tooth InformationOptionalMax 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 2010F Loop OptionalRepeat 10
- 1700Service Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level. - 1800Service Provider Supplemental IdentificationOptionalMax 8
To specify identifying information
Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send. - 2300Service Provider Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send. - 2400Service Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
- 1700Service Provider NameMandatoryMax 1
- 0100Service LevelMandatoryMax 1
- 0100Patient Event LevelMandatoryMax 1
- 0100Dependent LevelMandatoryMax 1
- 2000E Loop OptionalRepeat >1
- 0100Patient Event LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
Required when the information receiver has detected errors at the patient event or subsequent service levels of the notification or when a receipt number is assigned at the event level of a received notification. If not required by this implementation guide, do not send.Loop 2000E identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only. - 0200Patient Event Tracking NumberOptionalMax 3
To uniquely identify a transaction to an application
Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.If the 278 notification transaction passed 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 acknowledgment 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 acknowledgment transaction.If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source'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 acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number. - 0300Patient Event Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level. If not required by this implementation guide do not send. - 0400Health Care Services Review InformationMandatoryMax 1
To specify health care services review information
Required to identify the type of health care services review notification to which this acknowledgment pertains. - 0500Health Care Services ReviewOptionalMax 1
To specify the outcome of a health care services review
Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.If the acknowledgment 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. - 0600Administrative Reference NumberOptionalMax 1
To specify identifying information
Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver. - 0600Previous Review Authorization NumberOptionalMax 1
To specify identifying information
Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send. - 0700Event DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the valid date(s) during which this event can occur. If not required, do not send.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Admission DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the proposed or actual date of admission.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Discharge DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the proposed or actual date of discharge from a facility.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Issue DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment for the date when the certification was issued.Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Expiration DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0700Certification Effective DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send. - 0800Patient DiagnosisOptionalMax 1
To supply information related to the delivery of health care
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.This segment is used to hold the event level diagnosis code information that was part of the notification transaction. - 2010E Loop OptionalRepeat 12
- 1700Patient Event Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error. - 1800Patient Event Provider Supplemental IdentificationOptionalMax 7
To specify identifying information
Use the NM1 segment for the primary identifier.Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send. - 2300Patient Event Provider Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send. - 2400Patient Event Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
- 1700Patient Event Provider NameMandatoryMax 1
- 2000F Loop OptionalRepeat >1
- 0100Service LevelMandatoryMax 1
To identify dependencies among and the content of hierarchically related groups of data segments
Required when the information receiver has detected errors at this level of the notification, or assigns a receipt number to each service level on the notification that it receives. If not required by this implementation guide, do not send. - 0200Service Trace NumberOptionalMax 3
To uniquely identify a transaction to an application
Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.If the 278 notification transaction passed 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 acknowledgment 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 acknowledgment transaction.If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source'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 acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number. - 0300Service Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send. - 0400Health Care Services Review InformationOptionalMax 1
To specify health care services review information
Required when necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. If not required by this implementation guide, do not send. - 0500Health Care Services ReviewOptionalMax 1
To specify the outcome of a health care services review
Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification. - 0600Previous Review Authorization NumberOptionalMax 1
To specify identifying information
Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send. - 0600Administrative Reference NumberOptionalMax 1
To specify identifying information
Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver. - 0700Service DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Issue DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Expiration DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0700Certification Effective DateOptionalMax 1
To specify any or all of a date, a time, or a time period
Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0810Professional ServiceOptionalMax 1
To specify the service line item detail for a health care professional
Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0820Institutional Service LineOptionalMax 1
To specify the service line item detail for a health care institution
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0830Dental ServiceOptionalMax 1
To specify the service line item detail for dental work
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 0840Tooth InformationOptionalMax 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send. - 2010F Loop OptionalRepeat 10
- 1700Service Provider NameMandatoryMax 1
To supply the full name of an individual or organizational entity
Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level. - 1800Service Provider Supplemental IdentificationOptionalMax 8
To specify identifying information
Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send. - 2300Service Provider Request ValidationOptionalMax 9
To specify the validity of the request and indicate follow-up action authorized
Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send. - 2400Service Provider InformationOptionalMax 1
To specify the identifying characteristics of a provider
Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.
- 1700Service Provider NameMandatoryMax 1
- 0100Service LevelMandatoryMax 1
- 0100Patient Event LevelMandatoryMax 1
- 0100Subscriber LevelMandatoryMax 1
- 0100Information Receiver LevelMandatoryMax 1
- 0100Information Source LevelMandatoryMax 1
- 2800Transaction Set TrailerMandatoryMax 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)