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

0100Transaction Set HeaderMandatory->Max 1
To indicate the start of a transaction set and to assign a control number
0200Beginning 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. 0100Hierarchical LevelMandatory->Max 1
  To identify dependencies among and the content of hierarchically related groups of data segments
2. 0200TraceOptional->Max 9
  To uniquely identify a transaction to an application
3. 0300Request ValidationOptional->Max 9
  To specify the validity of the request and indicate follow-up action authorized
4. 0400Health Care Services Review InformationOptional->Max 1
  To specify health care services review information
5. 0500Health Care Services ReviewOptional->Max 1
  To specify the outcome of a health care services review
6. 0600Reference IdentificationOptional->Max 9
  To specify identifying information
7. 0700Date or Time or PeriodOptional->Max 9
  To specify any or all of a date, a time, or a time period
8. 0800Health Care Information CodesOptional->Max 1
  To supply information related to the delivery of health care
9. 0900Health Care Services DeliveryOptional->Max 1
  To specify the delivery pattern of health care services
10. 1000Conditions IndicatorOptional->Max 9
  To supply information on conditions
11. 1100Claim CodesOptional->Max 1
  To supply information specific to hospital claims
12. 1200Ambulance CertificationOptional->Max 1
  To supply information related to the ambulance service rendered to a patient
13. 1300Chiropractic CertificationOptional->Max 1
  To supply information related to the chiropractic service rendered to a patient
14. 1350Enteral or Parenteral Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
15. 1400Oxygen Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for home oxygen therapy
16. 1500Home Health Care CertificationOptional->Max 1
  To supply information related to the certification of a home health care patient
17. 1520Home Health Treatment Plan CertificationOptional->Max 1
  To supply information related to the home health care plan of treatment and services
18. 1530Pacemaker CertificationOptional->Max 1
  To supply information related to Pacemaker registry
19. 1550PaperworkOptional->Max >1
  To identify the type or transmission or both of paperwork or supporting information
20. 1600Message TextOptional->Max 1
  To provide a free-form format that allows the transmission of text information
21. NM1 Loop Optional
  Repeat >1
  1. 1700Individual or Organizational NameMandatory->Max 1
    To supply the full name of an individual or organizational entity
  2. 1800Reference IdentificationOptional->Max 9
    To specify identifying information
  3. 1900Additional Name InformationOptional->Max 1
    To specify additional names
  4. 2000Address InformationOptional->Max 1
    To specify the location of the named party
  5. 2100Geographic LocationOptional->Max 1
    To specify the geographic place of the named party
  6. 2200Administrative Communications ContactOptional->Max 3
    To identify a person or office to whom administrative communications should be directed
  7. 2300Request ValidationOptional->Max 9
    To specify the validity of the request and indicate follow-up action authorized
  8. 2400Provider InformationOptional->Max 1
    To specify the identifying characteristics of a provider
  9. 2500Demographic InformationOptional->Max 1
    To supply demographic information
  10. 2600Insured BenefitOptional->Max 1
    To provide benefit information on insured entities
  11. 2700Date or Time or PeriodOptional->Max 9
    To specify any or all of a date, a time, or a time period
2800Transaction 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)