EDI 278 Health Care Services Review Information

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.

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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 InformationOptional->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. 0810Professional ServiceOptional->Max 1
  To specify the service line item detail for a health care professional
10. 0820Institutional ServiceOptional->Max 1
  To specify the service line item detail for a health care institution
11. 0830Dental ServiceOptional->Max 1
  To specify the service line item detail for dental work
12. 0840Tooth IdentificationOptional->Max 32
  To identify a tooth by number and, if applicable, one or more tooth surfaces
13. 0850Tooth SummaryOptional->Max 35
  To specify the status of individual teeth
14. 0860Drug AuthorizationOptional->Max >1
  To specify a drug for which authorization is being requested
15. 0900Health Care Services DeliveryOptional->Max 1
  To specify the delivery pattern of health care services
16. 1000Conditions IndicatorOptional->Max 9
  To supply information on conditions
17. 1100Claim CodesOptional->Max 1
  To supply information specific to hospital claims
18. 1200Ambulance CertificationOptional->Max 1
  To supply information related to the ambulance service rendered to a patient
19. 1300Chiropractic CertificationOptional->Max 1
  To supply information related to the chiropractic service rendered to a patient
20. 1350Enteral or Parenteral Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
21. 1400Oxygen Therapy CertificationOptional->Max 1
  To supply information regarding certification of medical necessity for home oxygen therapy
22. 1500Home Health Care CertificationOptional->Max 1
  To supply information related to the certification of a home health care patient
23. 1520Home Health Treatment Plan CertificationOptional->Max 1
  To supply information related to the home health care plan of treatment and services
24. 1530Pacemaker CertificationOptional->Max 1
  To supply information related to Pacemaker registry
25. 1550PaperworkOptional->Max >1
  To identify the type or transmission or both of paperwork or supporting information
26. 1600Message TextOptional->Max 1
  To provide a free-form format that allows the transmission of text information
27. 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 InformationOptional->Max 9
    To specify identifying information
  3. 1900Additional Name InformationOptional->Max 1
    To specify additional names
  4. 2000Party LocationOptional->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)