EDI 278 Health Care Services 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.

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Heading

Position

Segment

Name

Max use

010Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
020Beginning of Hierarchical TransactionMandatory->Max 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

Position

Segment

Name

Max use

HL Loop Mandatory
Repeat >1
1. 010Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments
2. 020TraceOptional->Max 9
  To uniquely identify a transaction to an application
3. 030Request ValidationOptional->Max 9
  To specify the validity of the request and indicate follow-up action authorized
4. 040Health Care Services Review InformationOptional->Max 1
  To specify health care services review information
5. 050Health Care Services ReviewOptional->Max 1
  To specify the outcome of a health care services review
6. 060Reference IdentificationOptional->Max 9
  To specify identifying information
7. 070Date or Time or PeriodOptional->Max 9
  To specify any or all of a date, a time, or a time period
8. 080Health Care Information CodesOptional->Max 1
  To supply information related to the delivery of health care
9. 090Health Care Services DeliveryOptional->Max 1
  To specify the delivery pattern of health care services
10. 100Conditions IndicatorOptional->Max 9
  To supply information on conditions
11. 110Claim CodesOptional->Max 1
  To supply information specific to hospital claims
12. 120Ambulance CertificationOptional->Max 1
  To supply information related to the ambulance service rendered to a patient
13. 130Chiropractic CertificationOptional->Max 1
  To supply information related to the chiropractic service rendered to a patient
14. 135Enteral or Parenteral Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
15. 140Oxygen Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for home oxygen therapy
16. 150Home Health Care CertificationOptional->Max 1
  To supply information related to the certification of a home health care patient
17. 152Home Health Treatment Plan CertificationOptional->Max 1
  To supply information related to the home health care plan of treatment and services
18. 153Pacemaker CertificationOptional->Max 1
  To supply information related to Pacemaker registry
19. 155PaperworkOptional->Max >1
  To identify the type or transmission or both of paperwork or supporting information
20. 160Message TextOptional->Max 1
  To provide a free-form format that allows the transmission of text information
21. NM1 Loop Optional
  Repeat >1
  1. 170Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
  2. 180Reference IdentificationOptional->Max 9
    To specify identifying information
  3. 190Additional Name InformationOptional->Max 1
    To specify additional names or those longer than 35 characters in length
  4. 200Address InformationOptional->Max 1
    To specify the location of the named party
  5. 210Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  6. 220Administrative Communications ContactOptional->Max 3
    To identify a person or office to whom administrative communications should be directed
  7. 230Request ValidationOptional->Max 9
    To specify the validity of the request and indicate follow-up action authorized
  8. 240Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
  9. 250Demographic InformationOptional->Max 1
    To supply demographic information
  10. 260Insured BenefitOptional->Max 1
    To provide benefit information on insured entities
  11. 270Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
280Transaction Set TrailerMandatory->Max 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)