X12 278 Health Care Services Review Information - Response (X217)
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.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HI
- Health Care Services Review Information (278)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X217
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- This segment indicates the start of a health care services review information response transaction set with all the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management response.
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 278
- Health Care Services Review Information
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X217
Beginning of Hierarchical Transaction
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
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0007
- Information Source, Information Receiver, Subscriber, Dependent, Event, Services
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- Return the transaction identifier entered in BHT03 on the 278 request.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Code specifying the type of transaction
- 18
- Response - No Further Updates to Follow
Use this code to indicate that this is a final response. This indicates that no additional EDI responses are necessary or forthcoming from the UMO in relation to the original request.
- 19
- Response - Further Updates to Follow
Use this code to indicate that one or more of the services requested are pending further review and an EDI response will be delivered later.
- AT
- Administrative Action
BHT06 must be valued with "AT" if this 278 response contains a request for additional information.
Delivery of follow-up response(s) is as mutually agreed by trading partners.
- RU
- Medical Services Reservation
Use this code to respond to a request for medical services reservations.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.
- Y
- Yes
Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.
Code assigned by issuer to identify reason for rejection
- 04
- Authorized Quantity Exceeded
Use this code to indicate that the functional group exceeds the maximum number of transactions as specified by agreement between the application sender GS02 and application receiver GS03.
- 41
- Authorization/Access Restrictions
Use this code to indicate that the application sender (GS02) and application receiver (GS03) do not have a trading partner agreement for the transaction sets identified in GS01 or transaction sets with the purpose identified in BHT02. The 278 transaction set has three different implementations. The transaction set purpose, as identified in BHT02, specifies the implementation.
- 42
- Unable to Respond at Current Time
Use this code to indicate that the entity responsible for forwarding the request to the information source (Loop 2010A) is unable to process the transaction at the current time. This indicates a problem in the system forwarding the request and not in the information source's (UMO) system.
- 79
- Invalid Participant Identification
Use this code to indicate that the identifier used in GS02 or GS03 is invalid or unknown.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
Utilization Management Organization (UMO) Name
To supply the full name of an individual or organizational entity
- This segment identifies the source of information. In the case of a response to a request transaction, the information source would normally be the payer or utilization review organization who is the source of the decision regarding the request.
Code identifying an organizational entity, a physical location, property or an individual
- 2B
- Third-Party Administrator
- 36
- Employer
- PR
- Payer
- X3
- Utilization Management Organization
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual first name
Individual middle name or initial
Suffix to individual name
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- PI
- Payor Identification
Use when UMO is a payer and XV is not used.
- XV
- Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
Code identifying a party or other code
Utilization Management Organization (UMO) Contact Information
To identify a person or office to whom administrative communications should be directed
- Use this segment to identify a contact name and/or communications number for the UMO.
- Required when the requester must direct requests for follow-up to a specific UMO contact, email, facsimile, or telephone. If not required by this implementation guide, do not send.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Free-form name
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Utilization Management Organization (UMO) Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request cannot be processed at the system or application level based on the Utilization Management Organization (information source) identified in Loop 2010A. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 42
- Unable to Respond at Current Time
Use this code to indicate that the information source (UMO) identified in Loop 2010A is unable to process the transaction at the current time.
- 79
- Invalid Participant Identification
Use this code to indicate that the code used in Loop 2010A to identify the information source (UMO) is invalid.
- 80
- No Response received - Transaction Terminated
Use this code to indicate that the trading partner/application system responsible for sending the request to the information source (UMO) has not received a response in the expected timeframe and therefore has terminated the request.
- T4
- Payer Name or Identifier Missing
Use this code to indicate that either the name or identifier for the information source (UMO) identified in Loop 2010A is missing.
Code identifying follow-up actions allowed
- N
- Resubmission Not Allowed
- P
- Please Resubmit Original Transaction
- Y
- Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Requester Name
To supply the full name of an individual or organizational entity
- This loop identifies the receiver of information. In the case of a response to a request transaction, the receiver would normally be the provider who is receiving the decision.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
- FA
- Facility
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Requester Supplemental Identification
To specify identifying information
- Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- G5
- Provider Site Number
Use to identify the physician, clinic, or group practice associated with the requester identified in this NM1 loop.
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number must not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the requester/provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Requester Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Use this segment to convey rejection information regarding the entity that initiated a request transaction.
- Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use for missing contact information (PER Segment) other than phone number.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
Use if the provider is not authorized for requests.
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 79
- Invalid Participant Identification
Use for invalid/missing requester supplemental identifier.
- 97
- Invalid or Missing Provider Address
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
- R
- Resubmission Allowed
Requester Provider Information
To specify the identifying characteristics of a provider
- Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
- AS
- Assistant Surgeon
- AT
- Attending
- CO
- Consulting
- CV
- Covering
- OP
- Operating
- OR
- Ordering
- OT
- Other Physician
- PC
- Primary Care Physician
- PE
- Performing
- RF
- Referring
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Name
To supply the full name of an individual or organizational entity
- This segment identifies the subscriber.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
The value "II" when used in this data element, shall be defined as "HIPAA Individual Identifier" if this identifier has been adopted, under the Health Insurance Portability and Accountability Act of 1996, for use in this transaction.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
Code identifying a party or other code
Subscriber Supplemental Identification
To specify identifying information
- Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number are to be provided in the NM1 segment as a Member Identification Number when it is the primary number a UMO knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
- Required when used by the UMO to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- 1L
- Group or Policy Number
Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).
- 3L
- Branch Identifier
- 6P
- Group Number
- DP
- Department Number
- EJ
- Patient Account Number
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.
- F6
- Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there also is a need to pass the dependent's HIC number. This might occur in a Medicare HMO situation.
- HJ
- Identity Card Number
Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.
- IG
- Insurance Policy Number
- N6
- Plan Network Identification Number
- NQ
- Medicaid Recipient Identification Number
- SY
- Social Security Number
Use this code only if the Social Security Number is not the primary;identifier for the subscriber. The social security number may not be;used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Mailing Address
To specify the location of the named party
- Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 58
- Invalid/Missing Date-of-Birth
- 64
- Invalid/Missing Patient ID
- 65
- Invalid/Missing Patient Name
- 66
- Invalid/Missing Patient Gender Code
- 67
- Patient Not Found
- 68
- Duplicate Patient ID Number
- 71
- Patient Birth Date Does Not Match That for the Patient on the Database
- 72
- Invalid/Missing Subscriber/Insured ID
- 73
- Invalid/Missing Subscriber/Insured Name
- 74
- Invalid/Missing Subscriber/Insured Gender Code
- 75
- Subscriber/Insured Not Found
- 76
- Duplicate Subscriber/Insured ID Number
- 77
- Subscriber Found, Patient Not Found
- 78
- Subscriber/Insured Not in Group/Plan Identified
- 79
- Invalid Participant Identification
Use for invalid subscriber supplemental identifier.
- 95
- Patient Not Eligible
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Subscriber Demographic Information
To supply demographic information
- Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Relationship
To provide benefit information on insured entities
- Required when used by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- Y
- Yes
Code indicating the relationship between two individuals or entities
- 18
- Self
Code showing the general employment status of an employee/claimant
- Use to qualify the patient's relationship to the military.
- AO
- Active Military - Overseas
- AU
- Active Military - USA
- DI
- Deceased
- PV
- Previous
- RU
- Retired Military - USA
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Dependent Name
To supply the full name of an individual or organizational entity
- This segment conveys the name of the dependent who is the patient.
- NM108 and NM109 are situational on the response but Not Used on the request. This enables the UMO to return a unique member ID for the dependent that was not known to the requester at the time of the request. When the dependent has a unique member ID, Loop 2000D is not used.
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Code designating the system/method of code structure used for Identification Code (67)
- II
- Standard Unique Health Identifier for each Individual in the United States
The value "II" when used in this data element, shall be defined as "HIPAA Individual Identifier" if this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
Code identifying a party or other code
Dependent Supplemental Identification
To specify identifying information
- Required when used by the UMO to identify the Dependent or when REF01 = "EJ" (Patient Account Number) is valued on the request. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.
- SY
- Social Security Number
The social security number may not be used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Dependent Address
To specify the location of the named party
- Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Dependent City, State, ZIP Code
To specify the geographic place of the named party
- Required when used by the UMO to determine the appropriate location or network for service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Dependent Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use this code to indicate missing dependent relationship information.
- 33
- Input Errors
Use this code to indicate invalid dependent relationship information.
- 58
- Invalid/Missing Date-of-Birth
- 64
- Invalid/Missing Patient ID
- 65
- Invalid/Missing Patient Name
- 66
- Invalid/Missing Patient Gender Code
- 67
- Patient Not Found
- 68
- Duplicate Patient ID Number
- 71
- Patient Birth Date Does Not Match That for the Patient on the Database
- 77
- Subscriber Found, Patient Not Found
- 95
- Patient Not Eligible
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Dependent Demographic Information
To supply demographic information
- Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
- F
- Female
- M
- Male
- U
- Unknown
Dependent Relationship
To provide benefit information on insured entities
- Required when used by the UMO to determine the benefit/level of service for this patient. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- G8
- Other Relationship
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- EV
- Event
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Any trace numbers provided at this level on the request must be returned by the UMO at this level of the 278 response.
- If the 278 request transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:
If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 response transaction.
- If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.
- Required when this loop is returned and the request contained a tracking number at this level on the request, or when the UMO or clearinghouse assigns a trace number to this patient event in the response for tracking purposes. If not required by this implementation guide, do not send.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
The term "Current Transaction Trace Number" refers to the trace number assigned by the creator of the 278 response transaction (the UMO).
- 2
- Referenced Transaction Trace Numbers
The term "Referenced Transaction Trace Number" refers to the trace number originally sent in the 278 request transaction.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. If TRN01 is "2", this is the value received in the original 278 request transaction. If TRN01 is "1", use this information to identify the UMO organization that assigned this trace number.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Patient Event Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level. If not required by this implementation guide, do not send.
- Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another Reject Reason Code. For example, use for missing procedure codes and procedure dates.
- 33
- Input Errors
Use for input errors in the service data not covered by the other reject reason codes listed. For example, use for invalid place of service codes and invalid diagnosis codes and diagnosis dates.
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for Event Date(s).
- 56
- Inappropriate Date
Use when the type of date (Accident, Last Menstrual Period, Estimated Date of Birth, Onset of Current Symptoms or Illness) used on the request is inconsistent with the patient condition or services requested.
- 57
- Invalid/Missing Date(s) of Service
Use for invalid/missing event date.
- 60
- Date of Birth Follows Date(s) of Service
Use for Date(s) of Event.
- 61
- Date of Death Precedes Date(s) of Service
Use for Date(s) of Event.
- 62
- Date of Service Not Within Allowable Inquiry Period
Use for Date of Event.
- AA
- Authorization Number Not Found
- AF
- Invalid/Missing Diagnosis Code(s)
- AH
- Invalid/Missing Onset of Current Condition or Illness Date
- AI
- Invalid/Missing Accident Date
- AJ
- Invalid/Missing Last Menstrual Period Date
- AK
- Invalid/Missing Expected Date of Birth
- AM
- Invalid/Missing Admission Date
- AN
- Invalid/Missing Discharge Date
- T5
- Certification Information Missing
Use to indicate missing previous certification number information.
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Health Care Services Review Information
To specify health care services review information
- Identifies the type of health care services review.
Code indicating a type of request
- AR
- Admission Review
Required when this is a response to a request regarding admission to a facility.
- HS
- Health Services Review
Required when this is a response to a request for review of services related to an episode of care.
- IN
- Individual
Required when BHT06 is equal to "RU".
- SC
- Specialty Care Review
Required when this is a response to a request for a referral to a specialty provider.
Code indicating the type of certification
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of;service required is emergency or urgent. If UM02 = 1 then UM06 must be;valued.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service required is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Use this value to indicate that this is an extension request to a prior approved service.
- I
- Initial
- N
- Reconsideration
- R
- Renewal
Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.
- S
- Revised
Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
Use for restorative dental.
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 33
- Chiropractic
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 42
- Home Health Care
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 87
- Cancer
- 88
- Pharmacy
- 93
- Podiatry
- A4
- Psychiatric
- A6
- Psychotherapy
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AH
- Skilled Nursing Care - Room and Board
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BL
- Cardiac
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BS
- Invasive Procedures
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- CQ
- Case Management
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- Use to indicate a facility code value from the code source referenced in UM04-2.
Code identifying the type of facility referenced
- C023-02 qualifies C023-01 and C023-03.
- A
- Uniform Billing Claim Form Bill Type
- B
- Place of Service Codes for Professional or Dental Services
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Health Care Services Review
To specify the outcome of a health care services review
- If the UMO for this service was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
- If Loop 2000E is present in the response, either the AAA segment or the HCR segment must be returned in loop 2000E.
- If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 must be valued with the appropriate health care services review decision reason code to indicate that additional information is required.
Refer to Section 2.5 for more information.
- Required when the UMO has reviewed the request at this level to provide patient event review outcome information or to indicate that the final decision is pending. If not required by this implementation guide, do not send.
- If the response contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.
Code indicating type of action
- A1
- Certified in total
- A2
- Certified - partial
Use to identify that the event is only partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.
- A3
- Not Certified
- A4
- Pended
- A6
- Modified
- C
- Cancelled
- CT
- Contact Payer
- NA
- No Action Required
Use only if certification is not required.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- HCR02 is the number assigned by the information source to this review outcome.
Code indicating a code from a specific industry code list
- HCR03 is the code assigned by the information source to identify the reason for the health care service review outcome indicated in HCR01.See Code Source 886
- This data element is a repeating data element and can be repeated the maximum number allowed by the standard in this implementation guide.
Code indicating a Yes or No condition or response
- HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.
- N
- No
- Y
- Yes
Administrative Reference Number
To specify identifying information
- Required when the HCR segment is valued in this loop, HCR01 = A3, A4 or CT and the UMO has assigned an administrative reference number associated with this service review. If not required by this implementation guide, do not send.
- This number can be used by the requester on a follow up request, such as an appeal (UM02=1) or request for reconsideration (UM02=6), to reference this UMO response.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Previous Review Authorization Number
To specify identifying information
- Required when the certification number assigned by the UMO to the original service review outcome was used by the UMO to determine the outcome of this service review at the event level. If not required by this implementation guide, do not send.
- This is the authorization number assigned by the UMO to the original review outcome associated with this event. This is not the trace number assigned by the requester.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Accident Date
To specify any or all of a date, a time, or a time period
- Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Admission Date
To specify any or all of a date, a time, or a time period
- Required when the UMO authorizes admission for a specific date or date range. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 435
- Admission
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use this for the range of dates when admission can occur. Use the HSD segment for length of stay.
Expression of a date, a time, or range of dates, times or dates and times
Certification Effective Date
To specify any or all of a date, a time, or a time period
- Required when the authorization is limited by effective dates to indicate the date or date range when the authorization is effective. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 007
- Effective
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Certification Expiration Date
To specify any or all of a date, a time, or a time period
- Required when the authorization has an expiration date to indicate the date on which the authorization will expire. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 036
- Expiration
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Certification Issue Date
To specify any or all of a date, a time, or a time period
- Required when the UMO assigns a certification issue date to this authorization. If not required by this implementation guide, do not send.
- This is not the effective date of the authorization. The issue date is that date when the UMO issued the authorization.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 102
- Issue
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Required when the UMO authorizes services or admission based on the proposed or actual discharge date. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 096
- Discharge
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Estimated Date of Birth
To specify any or all of a date, a time, or a time period
- Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- ABC
- Estimated Date of Birth
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Event Date
To specify any or all of a date, a time, or a time period
- Required when the UMO authorizes service for a specific date or date range. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- AAH
- Event
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Last Menstrual Period Date
To specify any or all of a date, a time, or a time period
- Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Onset of Current Symptoms or Illness Date
To specify any or all of a date, a time, or a time period
- Required when valued on the request and used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
- The total number of DTP segments in the 2000E loop cannot exceed 9.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Patient Diagnosis
To supply information related to the delivery of health care
- If the response has not been rendered and this segment is used to request additional information associated with a specific diagnosis, place the specific diagnosis code in the HI C022 composite that precedes the HI C022 composite(s) containing the LOINC. If the original request contained more than six diagnosis codes and you are using LOINC to request additional information for each of these diagnosis codes or if you need to specify multiple questions/LOINC codes per diagnosis you cannot exceed the limit of 12 occurrences of the C022 composite.
- Required when used by the UMO to render a medical decision or if the UMO is requesting additional information. If not required by this implementation guide, do not send.
- The UMO can use each occurrence of the Health Care Code Information composite (C022) to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. In the C022 composite, data elements 1270 and 1271 support the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC®) List. These codes identify high-level health care information groupings, specific data elements, and associated modifiers.
Refer to Section 1.12.5.2 of this guide for more information on requesting additional information in the 278 response.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- BJ
- International Classification of Diseases Clinical Modification (ICD-9-CM) Admitting Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
See Section 2.5 for information on using LOINC to request additional information.
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- LOI
- Logical Observation Identifier Names and Codes (LOINC<190>) Codes
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Health Care Services Delivery
To specify the delivery pattern of health care services
- Required when the UMO authorizes services that have a specific pattern of delivery for the patient event. If not required by this implementation guide, do not send.
- Report authorized delivery patterns for specific services in the Service Level (Loop 2000F).
- An explanation of the uses of this segment follows.
HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit".
Between HSD02 and HSD03 verbally insert a "per every".
HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days".
The total message reads:
HSDVS1DA3721~ = "One visit per every three days for 21 days".
Another similar data string of HSDVS2DA4720~ = "Two visits per every four days for 20 days".
An alternate way to use HSD is to employ HSD07 and/or HSD08. A data string of HSDVS1****SXD~ means "1 visit on Wednesday and Thursday morning".
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- WE
- Weekend
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Institutional Claim Code
To supply information specific to hospital claims
- Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code indicating the priority of this admission
Code indicating the source of this admission
Code indicating patient status as of the "statement covers through date"
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Use this segment for certifications involving non-emergency transport of the patient.
- Required when used by the UMO to authorize specific non-emergency transport services. If not required by this implementation guide, do not send.
Code indicating the type of ambulance transport
- I
- Initial Trip
- R
- Return Trip
- T
- Transfer Trip
- X
- Round Trip
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
- DK
- Kilometers
Numeric value of quantity
- CR106 is the distance traveled during transport.
Spinal Manipulation Service Information
To supply information related to the chiropractic service rendered to a patient
- Required when used by the UMO to authorize spinal manipulation services that have a specific pattern of delivery usage. If not required by this implementation guide, do not send.
Occurrence counter
- CR201 is the number this treatment is in the series.
Numeric value of quantity
- CR202 is the total number of treatments in the series.
Code identifying the specific level of subluxation
- When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Code identifying the specific level of subluxation
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Home Oxygen Therapy Information
To supply information regarding certification of medical necessity for home oxygen therapy
- Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this implementation guide, do not send.
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Numeric value of quantity
- CR506 is the oxygen flow rate in liters per minute.
Numeric value of quantity
- CR507 is the number of times per day the patient must use oxygen.
Numeric value of quantity
- CR508 is the number of hours per period of oxygen use.
A free-form description to clarify the related data elements and their content
- CR509 is the special orders for the respiratory therapist.
Numeric value of quantity
- CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Code to indicate if a particular form of delivery was prescribed
- A
- Nasal Cannula
- B
- Oxygen Conserving Device
- C
- Oxygen Conserving Device with Oxygen Pulse System
- D
- Oxygen Conserving Device with Reservoir System
- E
- Transtracheal Catheter
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Home Health Care Information
To supply information related to the certification of a home health care patient
- Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
Code indicating physician's prognosis for the patient
- 1
- Poor
- 2
- Guarded
- 3
- Fair
- 4
- Good
- 5
- Very Good
- 6
- Excellent
- 7
- Less than 6 Months to Live
- 8
- Terminal
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR602 is the date covered home health services began.
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- CR604 is the certification period covered by this plan of treatment.
Code indicating a Yes or No condition or response
- CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
- W
- Not Applicable
Code indicating the type of certification
- This element must have the same value as UM02.
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service required is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
- 5
- Notification
- 6
- Verification
This code is used to request the UMO to reconsider a previously denied referral or certification request.
- I
- Initial
- R
- Renewal
- S
- Revised
Additional Patient Information
To identify the type or transmission or both of paperwork or supporting information
- If the UMO has pended the decision on this health care services review request (HCR01 = A4) because additional medical necessity information is required (HCR03 = 90), the UMO uses this segment to identify the type of documentation needed such as forms that the provider must complete. The UMO can also indicate what medium it has used to send these forms.
- Required when the UMO requests additional patient information. If not required by this implementation guide, do not send.
- Paperwork requested at the patient level should apply to the patient event and/or all the services requested. Use the PWK segment in the appropriate Service loop if requesting medical necessity information for a specific service.
- This PWK segment is required to identify requests for specific data that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the response. PWK06 is used to identify the attached electronic questionnaire. The number in PWK06 should be referenced in the corresponding electronic attachment.
- This PWK segment should not be used if
a. the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.
b. the 278 request (ST-SE) does not support this information and the needed information pertains to a specific service identified in Loop 2000F and not to all the services requested.
Refer to Section 2.5 for more information on using this segment.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
A free-form description to clarify the related data elements and their content
- PWK07 may be used to indicate special information to be shown on the specified report.
Message Text
To provide a free-form format that allows the transmission of text information
- Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
Additional Patient Information Contact Name
To supply the full name of an individual or organizational entity
- Required when this Loop 2000E contains a request for additional information and the destination for that additional information differs from the UMO Name information in the NM1 loop (Loop 2010A) of the 278 response. If not required by this implementation guide, do not send.
- Because the usage of this segment is "Situational" this is not a syntactically required loop. If this loop is used, then this segment is a "Required" segment. See Appendix A for further details on ASC X12;syntax rules.
Refer to Section 2.5 for more information on this NM1 loop.
Code identifying an organizational entity, a physical location, property or an individual
- L5
- Contact
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Use this name only if the destination is an individual, such as an individual primary care physician.
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- PI
- Payor Identification
Use when destination is a payer and XV is not used.
- XV
- Centers for Medicare and Medicaid Services PlanID
Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Use if the destination is a provider.
Code identifying a party or other code
Additional Patient Information Contact Address
To specify the location of the named party
- This segment identifies the office location to route the response to the request for additional patient information.
- Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Additional Patient Information Contact City, State, ZIP Code
To specify the geographic place of the named party
- Required when the response to the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Additional Patient Information Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
- By definition of the standard, if PER03 is used, PER04 is required.
- Required when the provider must direct the response to the request for additional patient information to a specific requester contact, electronic mail, facsimile, or phone number other than the contact provided in the PER segment in the UMO Name loop (Loop 2010A) PER segment of this 278 response. If not required by this implementation guide, do not send.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
Complete communications number including country or area code when applicable
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- Required when valued on the request or when the UMO authorizes a specific provider or specialty entity for this patient event. If not required by this implementation guide, do not send.
- Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
Code identifying an organizational entity, a physical location, property or an individual
- 71
- Attending Physician
- 72
- Operating Physician
- 73
- Other Physician
- 77
- Service Location
- AAJ
- Admitting Services
- DD
- Assistant Surgeon
- DK
- Ordering Physician
- DN
- Referring Provider
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- 24
- Employer's Identification Number
- 34
- Social Security Number
- 46
- Electronic Transmitter Identification Number (ETIN)
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the UMO.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the UMO has the capability to send it.
If not required by this implementation guide, do not send.
Code identifying a party or other code
Patient Event Provider Supplemental Identification
To specify identifying information
- Required when used by the UMO to identify the Patient Event Provider. If not required by this implementation guide, do not send.
- Use the NM1 segment for the primary identifier.
Code qualifying the Reference Identification
- 0B
- State License Number
- 1G
- Provider UPIN Number
- 1J
- Facility ID Number
- EI
- Employer's Identification Number
Not used if NM108 = 24.
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- SY
- Social Security Number
The social security number must not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use for the provider ID as assigned by the UMO identified in Loop 2000A.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Address
To specify the location of the named party
- Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.
Patient Event Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when the UMO authorizes a specific location for a patient event provider that has multiple locations. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
- By definition of the standard, if PER03 is used, PER04 is required.
- Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Patient Event Provider Request Validation
To specify the validity of the request and indicate follow-up action authorized
- Required when the request is not valid at this level to indicate the data condition that prohibits processing of the original request. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
- N
- No
Code assigned by issuer to identify reason for rejection
- 15
- Required application data missing
Use when data is missing that is not covered by another reject reason code. Use to indicate when there is not enough information to identify the provider.
- 33
- Input Errors
Use for input errors not covered by another reject reason code.
- 35
- Out of Network
- 41
- Authorization/Access Restrictions
- 43
- Invalid/Missing Provider Identification
- 44
- Invalid/Missing Provider Name
- 45
- Invalid/Missing Provider Specialty
- 46
- Invalid/Missing Provider Phone Number
- 47
- Invalid/Missing Provider State
- 49
- Provider is Not Primary Care Physician
- 51
- Provider Not on File
- 52
- Service Dates Not Within Provider Plan Enrollment
Use for patient event dates.
- 79
- Invalid Participant Identification
Use for invalid/missing provider supplemental identifier.
- 97
- Invalid or Missing Provider Address
- IP
- Inappropriate Provider Role
Code identifying follow-up actions allowed
- C
- Please Correct and Resubmit
- N
- Resubmission Not Allowed
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
Use only when NM101 = AAJ.
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- AT
- Attending
Use only when NM101 = 71.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
- RF
- Referring
Use only when NM101 = DN.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Patient Event Transport Information
To supply the full name of an individual or organizational entity
- Required when used by the UMO to authorize specific transport services. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
- FS
- Final Scheduled Destination
- ND
- Next Destination
- PW
- Pickup Address
- R3
- Next Scheduled Destination
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Patient Event Transport Location Address
To specify the location of the named party
Patient Event Transport Location City/State/ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.