EDI 274 Healthcare Provider Information

Functional Group PW

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Healthcare Provider Information Transaction Set (274) for use within the context of an Electronic Data Interchange (EDI) environment. This standard can be used to exchange demographic and educational/professional qualifications about healthcare providers between providers, provider networks or any other entity that maintains or verifies healthcare provider information. Such exchanges include the transmitting, inquirying, or responding to an inquiry. Healthcare provider information is routinely exchanged for the purpose of 1) maintaining provider data bases for claim adjudication, provider directories, patient referrals, and reporting provider information, 2) submitting an application to join a provider organization or provider network such as, but not limited to, a hospital, preferred provider organization (PPO) or health maintenance organization (HMO), and 3) verifying credentials such as educational/professional qualifications, licenses, and malpractice coverage/history.

Heading

1. 0100 · ST · Transaction Set Header · Max 1 · Mandatory

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

2. 0200 · 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

3. 0300 · DTM · Date/Time Reference · Max 1 · Optional

   To specify pertinent dates and times

4. 0400 · PER · Administrative Communications Contact · Max 1 · Optional

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

   The PER segment is used to supply the sender's point of contact to the receiver.

Detail

1. 2000 Loop Mandatory Repeat >1

   1. 0100 · HL · Hierarchical Level · Max 1 · Mandatory

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

      Valid hierarchical level codes for this transaction set are information source, information receiver, provider, group and site of service.

   2. 0200 · TRN · Trace · Max 1 · Optional

      To uniquely identify a transaction to an application

      The TRN segment is used to identify trace numbers that provide an electronic link between this transaction and other transactions.

   3. 0250 · AAA · Request Validation · Max 1 · Optional

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

   4. 2100 Loop Mandatory Repeat >1

      1. 0300 · NM1 · Individual or Organizational Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         The NM1 segment is used to identify individuals and entities related to the hierarchical level identified by HL03.

      2. 0400 · N2 · Additional Name Information · Max >1 · Optional

         To specify additional names

      3. 0500 · PER · Administrative Communications Contact · Max >1 · Optional

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

      4. 0600 · DMG · Demographic Information · Max 1 · Optional

         To supply demographic information

      5. 0700 · AMT · Monetary Amount Information · Max 20 · Optional

         To indicate the total monetary amount

      6. 0800 · API · Activity or Process Information · Max >1 · Optional

         To provide information on activity or process

      7. 0900 · DEG · Degree Record · Max 9 · Optional

         To provide information about an educational institution's academic award

      8. 1000 · IND · Additional Individual Demographic Information · Max 1 · Optional

         To provide additional demographic information to the receiving school, institution, or agency to assist in identifying the particular student

      9. 1100 · LUI · Language Use · Max 9 · Optional

         To specify language, type of usage, and proficiency or fluency

      10. 1200 · DTP · Date or Time or Period · Max 9 · Optional

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

      11. 1250 · AAA · Request Validation · Max 1 · Optional

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

      12. 1300 · MTX · Text · Max >1 · Optional

          To specify textual data

      13. 1400 · QTY · Quantity Information · Max 99 · Optional

          To specify quantity information

      14. 1500 · WS · Work Schedule · Max 99 · Optional

          To specify an individual's work schedule

      15. 1600 · CRC · Conditions Indicator · Max 9 · Optional

          To supply information on conditions

      16. 1700 · HSD · Health Care Services Delivery · Max 99 · Optional

          To specify the delivery pattern of health care services

      17. 1800 · BCI · Basic Claim Information · Max 9 · Optional

          To identify information basic to the processing of any claims transaction

      18. 1900 · PDI · Practice Detail Information · Max 1 · Optional

          To provide detail information on a health care provider's practice

      19. 2000 · HAD · Hospital Affiliation Detail · Max 1 · Optional

          To provide detail information describing a provider's affiliation to a specific hospital

      20. 2050 · ACT · Account Identification · Max 1 · Optional

          To specify account information

      21. 2110 Loop Optional Repeat >1

          1. 2100 · NX1 · Property or Entity Identification · Max 1 · Mandatory

             To define the attributes of a property or an entity

             Loop 2110 provides multiple addresses related to the entity identified in the NM1 segment. The NX1 segment provides the type of address for each iteration of the loop. For instance, billing service or place of business.

          2. 2200 · N2 · Additional Name Information · Max 1 · Optional

             To specify additional names

          3. 2300 · N3 · Party Location · Max 2 · Optional

             To specify the location of the named party

          4. 2400 · N4 · Geographic Location · Max 1 · Optional

             To specify the geographic place of the named party

          5. 2500 · PER · Administrative Communications Contact · Max 1 · Optional

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

          6. 2550 · AAA · Request Validation · Max 1 · Optional

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

      22. 2120 Loop Optional Repeat >1

          1. 2600 · LQ · Industry Code Identification · Max 1 · Mandatory

             To identify standard industry codes

          2. 2700 · N1 · Party Identification · Max 2 · Optional

             To identify a party by type of organization, name, and code

          3. 2800 · TPB · Business Professional Title · Max >1 · Optional

             To identify title of an individual within a company

          4. 2900 · DTP · Date or Time or Period · Max 9 · Optional

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

          5. 3000 · QTY · Quantity Information · Max 1 · Optional

             To specify quantity information

          6. 3100 · YNQ · Yes/No Question · Max >1 · Optional

             To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

          7. 3150 · AAA · Request Validation · Max 1 · Optional

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

      23. 2130 Loop Optional Repeat 99

          1. 3200 · HPL · Health Care Provider License · Max 1 · Mandatory

             To provide license, certification, accreditation, and registration information for health care providers

          2. 3300 · DTP · Date or Time or Period · Max >1 · Optional

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

          3. 3350 · AAA · Request Validation · Max 1 · Optional

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

      24. 2140 Loop Optional Repeat >1

          1. 3400 · REF · Reference Information · Max 1 · Mandatory

             To specify identifying information

          2. 3500 · DTP · Date or Time or Period · Max 9 · Optional

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

          3. 3550 · AAA · Request Validation · Max 1 · Optional

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

      25. 2150 Loop Optional Repeat 9

          1. 3600 · EMS · Employment Position · Max 1 · Mandatory

             To describe employment position

          2. 3700 · DTP · Date or Time or Period · Max 9 · Optional

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

      26. 2160 Loop Optional Repeat >1

          1. 3710 · LX · Transaction Set Line Number · Max 1 · Mandatory

             To reference a line number in a transaction set

          2. 3720 · PER · Administrative Communications Contact · Max 1 · Optional

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

          3. 3730 · REF · Reference Information · Max 1 · Optional

             To specify identifying information

          4. 3740 · DTP · Date or Time or Period · Max 1 · Optional

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

          5. 3750 · OOI · Associated Object Type Identification · Max 1 · Optional

             To identify attributes and status related to the object

          6. 3760 · BDS · Binary Data Structure · Max 1 · Optional

             To transfer binary data in a single data segment, convey a critical filter for transmission and allow identification of the end of the data segment through a count; there is no identification of the internal structure of the binary data in this segment

          7. 3770 · AAA · Request Validation · Max 1 · Optional

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

2. 3800 · 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)