UM Health Care Services Review Information

To specify health care services review information

Position: UM-01 · Element: 1525 · Name: Request Category Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 1 · Max: 2 · Repeat: 1

Code indicating a type of request

Position: UM-02 · Element: 1322 · Name: Certification Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating the type of certification

Position: UM-03 · Element: 1365 · Name: Service Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code identifying the classification of service

UM-04 C023 Health Care Service Location Information Composite (composite) Optional 1

Position: 01 · Element: 1331 · Name: Facility Code Value · Type: String (AN) · Requirement: Mandatory · Min: 1 · Max: 3 · Repeat: -

Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).

Position: 02 · Element: 1332 · Name: Facility Code Qualifier · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: -

Code identifying the type of facility referenced

C023-02 qualifies C023-01 and C023-03.

Position: 03 · Element: 1325 · Name: Claim Frequency Type Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: -

Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type

UM-05 C024 Related Causes Information Composite (composite) Optional 1

Position: 01 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Mandatory · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 02 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 03 · Element: 1362 · Name: Related-Causes Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying an accompanying cause of an illness, injury or an accident

Position: 04 · Element: 156 · Name: State or Province Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 2 · Repeat: -

Code (Standard State/Province) as defined by appropriate government agency

C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".

Position: 05 · Element: 26 · Name: Country Code · Type: Identifier (ID) · Requirement: Optional · Min: 2 · Max: 3 · Repeat: -

Code identifying the country

Position: UM-06 · Element: 1338 · Name: Level of Service Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 3 · Repeat: 1

Code specifying the level of service rendered

Position: UM-07 · Element: 1213 · Name: Current Health Condition Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating current health condition of the individual

Position: UM-08 · Element: 923 · Name: Prognosis Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating physician's prognosis for the patient

Position: UM-09 · Element: 1363 · Name: Release of Information Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 1 · Repeat: 1

Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations

Position: UM-10 · Element: 1514 · Name: Delay Reason Code · Type: Identifier (ID) · Requirement: Optional · Min: 1 · Max: 2 · Repeat: 1

Code indicating the reason why a request was delayed