EDI 278 Health Care Service Review Information

Functional Group HI

X12N Insurance Subcommittee

This Draft Standard for Trial Use 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. 010 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 020 · 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. HL Loop Mandatory Repeat >1

   1. 010 · HL · Hierarchical Level · Max 1 · Mandatory

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

   2. 020 · TRN · Trace · Max 9 · Optional

      To uniquely identify a transaction to an application.

   3. 030 · AAA · Request Validation · Max 9 · Optional

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

   4. 040 · UM · Health Care Services Review Information · Max 1 · Optional

      To specify health care services review information

   5. 050 · HCR · Health Care Services Review · Max 1 · Optional

      To specify the outcome of a health care services review

   6. 060 · REF · Reference Numbers · Max 9 · Optional

      To specify identifying numbers.

   7. 070 · DTP · Date or Time or Period · Max 9 · Optional

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

   8. 080 · HI · Health Care Information Codes · Max 1 · Optional

      To supply information related to the delivery of health care

   9. 090 · HSD · Health Care Services Delivery · Max 1 · Optional

      To specify the delivery pattern of health care services

   10. 100 · CRC · Conditions Indicator · Max 9 · Optional

       To supply information on conditions

   11. 110 · CL1 · Claim Codes · Max 1 · Optional

       To supply information specific to hospital claims

   12. 120 · CR1 · Ambulance Certification · Max 1 · Optional

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

   13. 130 · CR2 · Chiropractic Certification · Max 1 · Optional

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

   14. 140 · CR5 · Oxygen Therapy Certification · Max 1 · Optional

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

   15. 150 · CR6 · Home Health Care Certification · Max 1 · Optional

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

   16. 160 · MSG · Message Text · Max 1 · Optional

       To provide a free form format that would allow the transmission of text information.

   17. NM1 Loop Optional Repeat >1

       1. 170 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

          To supply the full name of an individual or organizational entity

       2. 180 · REF · Reference Numbers · Max 9 · Optional

          To specify identifying numbers.

       3. 190 · N2 · Additional Name Information · Max 1 · Optional

          To specify additional names or those longer than 35 characters in length

       4. 200 · N3 · Address Information · Max 1 · Optional

          To specify the location of the named party

       5. 210 · N4 · Geographic Location · Max 1 · Optional

          To specify the geographic place of the named party

       6. 220 · PER · Administrative Communications Contact · Max 3 · Optional

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

       7. 230 · AAA · Request Validation · Max 9 · Optional

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

       8. 240 · PRV · Provider Information · Max 1 · Optional

          To specify the identifying characteristics of a provider

       9. 250 · DMG · Demographic Information · Max 1 · Optional

          To supply demographic information

       10. 260 · INS · Insured Benefit · Max 1 · Optional

           To provide benefit information on insured entities

       11. 270 · DTP · Date or Time or Period · Max 9 · Optional

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

2. 280 · 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).