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Health Care Services Review Information - Response (X217)
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X12 278 Health Care Services Review Information - Response (X217)

X12 Release 5010

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.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
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    Overview
    ISA
    -
    Interchange Control Header
    Max use 1
    Required
    GS
    -
    Functional Group Header
    Max use 1
    Required
    heading
    detail
    Utilization Management Organization (UMO) Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    AAA
    0300
    Request Validation
    Max use 9
    Optional
    Requester Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Subscriber Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Dependent Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    Patient Event Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    TRN
    0200
    Patient Event Tracking Number
    Max use 3
    Optional
    AAA
    0300
    Patient Event Request Validation
    Max use 9
    Optional
    UM
    0400
    Health Care Services Review Information
    Max use 1
    Required
    HCR
    0500
    Health Care Services Review
    Max use 1
    Optional
    REF
    0600
    Administrative Reference Number
    Max use 1
    Optional
    REF
    0600
    Previous Review Authorization Number
    Max use 1
    Optional
    DTP
    0700
    Accident Date
    Max use 1
    Optional
    DTP
    0700
    Admission Date
    Max use 1
    Optional
    DTP
    0700
    Certification Effective Date
    Max use 1
    Optional
    DTP
    0700
    Certification Expiration Date
    Max use 1
    Optional
    DTP
    0700
    Certification Issue Date
    Max use 1
    Optional
    DTP
    0700
    Discharge Date
    Max use 1
    Optional
    DTP
    0700
    Estimated Date of Birth
    Max use 1
    Optional
    DTP
    0700
    Event Date
    Max use 1
    Optional
    DTP
    0700
    Last Menstrual Period Date
    Max use 1
    Optional
    DTP
    0700
    Onset of Current Symptoms or Illness Date
    Max use 1
    Optional
    HI
    0800
    Patient Diagnosis
    Max use 1
    Optional
    HSD
    0900
    Health Care Services Delivery
    Max use 1
    Optional
    CL1
    1100
    Institutional Claim Code
    Max use 1
    Optional
    CR1
    1200
    Ambulance Transport Information
    Max use 1
    Optional
    CR2
    1300
    Spinal Manipulation Service Information
    Max use 1
    Optional
    CR5
    1400
    Home Oxygen Therapy Information
    Max use 1
    Optional
    CR6
    1500
    Home Health Care Information
    Max use 1
    Optional
    PWK
    1550
    Additional Patient Information
    Max use 10
    Optional
    MSG
    1600
    Message Text
    Max use 1
    Optional
    Service Level Loop
    HL
    0100
    Hierarchical Level
    Max use 1
    Required
    TRN
    0200
    Service Trace Number
    Max use 3
    Optional
    AAA
    0300
    Service Request Validation
    Max use 9
    Optional
    UM
    0400
    Health Care Services Review Information
    Max use 1
    Optional
    HCR
    0500
    Health Care Services Review
    Max use 1
    Optional
    REF
    0600
    Administrative Reference Number
    Max use 1
    Optional
    REF
    0600
    Previous Review Authorization Number
    Max use 1
    Optional
    DTP
    0700
    Certification Effective Date
    Max use 1
    Optional
    DTP
    0700
    Certification Expiration Date
    Max use 1
    Optional
    DTP
    0700
    Certification Issue Date
    Max use 1
    Optional
    DTP
    0700
    Service Date
    Max use 1
    Optional
    HI
    0800
    Request For Additional Information
    Max use 1
    Optional
    SV1
    0810
    Professional Service
    Max use 1
    Optional
    SV2
    0820
    Institutional Service Line
    Max use 1
    Optional
    SV3
    0830
    Dental Service
    Max use 1
    Optional
    TOO
    0840
    Tooth Information
    Max use 32
    Optional
    HSD
    0900
    Health Care Services Delivery
    Max use 1
    Optional
    PWK
    1550
    Additional Service Information
    Max use 10
    Optional
    MSG
    1600
    Message Text
    Max use 1
    Optional
    SE
    2800
    Transaction Set Trailer
    Max use 1
    Required
    GE
    -
    Functional Group Trailer
    Max use 1
    Required
    IEA
    -
    Interchange Control Trailer
    Max use 1
    Required
    ISA

    Interchange Control Header

    RequiredMax use 1

    To start and identify an interchange of zero or more functional groups and interchange-related control segments

    Example
    ISA-01
    I01
    Authorization Information Qualifier
    Required

    Code identifying the type of information in the Authorization Information

    00
    No Authorization Information Present (No Meaningful Information in I02)
    ISA-02
    I02
    Authorization Information
    Required
    Min 10Max 10

    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)

    ISA-03
    I03
    Security Information Qualifier
    Required

    Code identifying the type of information in the Security Information

    00
    No Security Information Present (No Meaningful Information in I04)
    ISA-04
    I04
    Security Information
    Required
    Min 10Max 10

    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)

    ISA-05
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

    Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

    Codes
    ISA-06
    I06
    Interchange Sender ID
    Required
    Min 15Max 15

    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

    ISA-07
    I05
    Interchange ID Qualifier
    Required
    Min 2Max 2

    Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

    Codes
    ISA-08
    I07
    Interchange Receiver ID
    Required
    Min 15Max 15

    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

    ISA-09
    I08
    Interchange Date
    Required
    YYMMDD format

    Date of the interchange

    ISA-10
    I09
    Interchange Time
    Required
    HHMM format

    Time of the interchange

    ISA-11
    I65
    Repetition Separator
    Required
    Min 1Max 1

    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
    ISA-12
    I11
    Interchange Control Version Number
    Required

    Code specifying the version number of the interchange control segments

    00501
    Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
    ISA-13
    I12
    Interchange Control Number
    Required
    Min 9Max 9

    A control number assigned by the interchange sender

    ISA-14
    I13
    Acknowledgment Requested
    Required
    Min 1Max 1

    Code indicating sender's request for an interchange acknowledgment

    0
    No Interchange Acknowledgment Requested
    1
    Interchange Acknowledgment Requested (TA1)
    ISA-15
    I14
    Interchange Usage Indicator
    Required
    Min 1Max 1

    Code indicating whether data enclosed by this interchange envelope is test, production or information

    I
    Information
    P
    Production Data
    T
    Test Data
    ISA-16
    I15
    Component Element Separator
    Required
    Min 1Max 1

    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

    RequiredMax use 1

    To indicate the beginning of a functional group and to provide control information

    Example
    GS-01
    479
    Functional Identifier Code
    Required

    Code identifying a group of application related transaction sets

    HI
    Health Care Services Review Information (278)
    GS-02
    142
    Application Sender's Code
    Required
    Min 2Max 15

    Code identifying party sending transmission; codes agreed to by trading partners

    GS-03
    124
    Application Receiver's Code
    Required
    Min 2Max 15

    Code identifying party receiving transmission; codes agreed to by trading partners

    GS-04
    373
    Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    GS-05
    337
    Time
    Required
    HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

    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)

    GS-06
    28
    Group Control Number
    Required
    Min 1Max 9

    Assigned number originated and maintained by the sender

    GS-07
    455
    Responsible Agency Code
    Required
    Min 1Max 2

    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
    GS-08
    480
    Version / Release / Industry Identifier Code
    Required

    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
    ANSI ASC X12 Health Care Services Review Information (278) for requests for review and responses to such requests through May 2006

    Heading

    ST
    0100

    Transaction Set Header

    RequiredMax use 1

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

    Usage notes
    • 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.
    Example
    ST-01
    143
    Transaction Set Identifier Code
    Required

    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
    ST-02
    329
    Transaction Set Control Number
    Required
    Min 4Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

    Usage notes
    • 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.
    ST-03
    1705
    Implementation Guide Version Name
    Required

    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.
    Usage notes
    • 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
    BHT
    0200

    Beginning of Hierarchical Transaction

    RequiredMax use 1

    To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

    Example
    BHT-01
    1005
    Hierarchical Structure Code
    Required

    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
    BHT-02
    353
    Transaction Set Purpose Code
    Required

    Code identifying purpose of transaction set

    11
    Response
    BHT-03
    127
    Submitter Transaction Identifier
    Required
    Min 1Max 50

    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.
    Usage notes
    • Return the transaction identifier entered in BHT03 on the 278 request.
    BHT-04
    373
    Transaction Set Creation Date
    Required
    CCYYMMDD format

    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.
    BHT-05
    337
    Transaction Set Creation Time
    Required
    HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

    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.
    BHT-06
    640
    Transaction Type Code
    Required

    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

    2000A Utilization Management Organization (UMO) Level Loop
    RequiredMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    AAA
    0300

    Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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.

    AAA-03
    901
    Reject Reason Code
    Required

    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.

    AA
    Authorization Number Not Found
    AAA-04
    889
    Follow-up Action Code
    Required

    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
    2010A Utilization Management Organization (UMO) Name Loop
    RequiredMax 1
    NM1
    1700

    Utilization Management Organization (UMO) Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • 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.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    2B
    Third-Party Administrator
    36
    Employer
    PR
    Payer
    X3
    Utilization Management Organization
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Utilization Management Organization (UMO) Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Utilization Management Organization (UMO) First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Utilization Management Organization (UMO) Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Utilization Management Organization (UMO) Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

    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).

    NM1-09
    67
    Utilization Management Organization (UMO) Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    PER
    2200

    Utilization Management Organization (UMO) Contact Information

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    If either Communication Number Qualifier (PER-03) or Utilization Management Organization (UMO) Contact Communication Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Utilization Management Organization (UMO) Contact Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Utilization Management Organization (UMO) Contact Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    IC
    Information Contact
    PER-02
    93
    Utilization Management Organization (UMO) Contact Name
    Optional
    Min 1Max 60

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Optional

    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.

    PER-04
    364
    Utilization Management Organization (UMO) Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    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.

    PER-06
    364
    Utilization Management Organization (UMO) Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    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.

    PER-08
    364
    Utilization Management Organization (UMO) Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    AAA
    2300

    Utilization Management Organization (UMO) Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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.

    AAA-04
    889
    Follow-up Action Code
    Required

    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
    2000B Requester Level Loop
    OptionalMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-02
    734
    Hierarchical Parent ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    2010B Requester Name Loop
    RequiredMax 2
    NM1
    1700

    Requester Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • 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.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    1P
    Provider
    FA
    Facility
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Requester Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Requester First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Requester Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Requester Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

    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
    NM1-09
    67
    Requester Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Requester Supplemental Identification

    OptionalMax use 8

    To specify identifying information

    Usage notes
    • Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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.

    REF-02
    127
    Requester Supplemental Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    AAA
    2300

    Requester Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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.

    42
    Unable to Respond at Current Time
    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
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    P
    Please Resubmit Original Transaction
    R
    Resubmission Allowed
    PRV
    2400

    Requester Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when used by the UMO to identify the requester. If not required by this implementation guide, do not send.
    Example
    If either Reference Identification Qualifier (PRV-02) or Provider Taxonomy Code (PRV-03) is present, then the other is required
    PRV-01
    1221
    Provider Code
    Required

    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
    PRV-02
    128
    Reference Identification Qualifier
    Optional

    Code qualifying the Reference Identification

    PXC
    Health Care Provider Taxonomy Code
    PRV-03
    127
    Provider Taxonomy Code
    Optional
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    2000C Subscriber Level Loop
    OptionalMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-02
    734
    Hierarchical Parent ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    2010C Subscriber Name Loop
    RequiredMax 1
    NM1
    1700

    Subscriber Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • This segment identifies the subscriber.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    IL
    Insured or Subscriber
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    NM1-03
    1035
    Subscriber Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Subscriber First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Subscriber Middle Name or Initial
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-06
    1038
    Subscriber Name Prefix
    Optional
    Min 1Max 10

    Prefix to individual name

    NM1-07
    1039
    Subscriber Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Required

    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.

    NM1-09
    67
    Subscriber Primary Identifier
    Required
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Subscriber Supplemental Identification

    OptionalMax use 9

    To specify identifying information

    Usage notes
    • 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.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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.

    REF-02
    127
    Subscriber Supplemental Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    N3
    2000

    Subscriber Mailing Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • 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.
    Example
    N3-01
    166
    Subscriber Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the Subscriber address.
    N3-02
    166
    Subscriber Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Subscriber City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • 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.
    Example
    Only one of Subscriber State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Subscriber City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Subscriber State Code
    Optional
    Min 2Max 2

    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.
    N4-03
    116
    Subscriber Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    AAA
    2300

    Subscriber Request Validation

    OptionalMax use 9

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

    Usage notes
    • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    DMG
    2500

    Subscriber Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

    Code indicating the date format, time format, or date and time format

    D8
    Date Expressed in Format CCYYMMDD
    DMG-02
    1251
    Subscriber Birth Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    • DMG02 is the date of birth.
    DMG-03
    1068
    Subscriber Gender Code
    Optional

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    INS
    2600

    Subscriber Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

    Usage notes
    • Required when used by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
    Example
    INS-01
    1073
    Insured Indicator
    Required

    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
    INS-02
    1069
    Individual Relationship Code
    Required

    Code indicating the relationship between two individuals or entities

    18
    Self
    INS-08
    584
    Employment Status Code
    Required

    Code showing the general employment status of an employee/claimant

    Usage notes
    • 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
    2000D Dependent Level Loop
    OptionalMax 1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-02
    734
    Hierarchical Parent ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    2010D Dependent Name Loop
    RequiredMax 1
    NM1
    1700

    Dependent Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • 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.
    Example
    If either Identification Code Qualifier (NM1-08) or Dependent Primary Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    QC
    Patient
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    NM1-03
    1035
    Dependent Last Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Dependent First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Dependent Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Dependent Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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.

    NM1-09
    67
    Dependent Primary Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Dependent Supplemental Identification

    OptionalMax use 3

    To specify identifying information

    Usage notes
    • 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.
    Example
    REF-01
    128
    Reference Identification Qualifier
    Required

    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.

    REF-02
    127
    Dependent Supplemental Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    N3
    2000

    Dependent Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • 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.
    Example
    N3-01
    166
    Dependent Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the Dependent address.
    N3-02
    166
    Dependent Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Dependent City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • 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.
    Example
    Only one of Dependent State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Dependent City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Dependent State Code
    Optional
    Min 2Max 2

    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.
    N4-03
    116
    Dependent Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    AAA
    2300

    Dependent Request Validation

    OptionalMax use 9

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

    Usage notes
    • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    DMG
    2500

    Dependent Demographic Information

    OptionalMax use 1

    To supply demographic information

    Usage notes
    • Required when used by the UMO to determine medical necessity. If not required by this implementation guide, do not send.
    Example
    DMG-01
    1250
    Date Time Period Format Qualifier
    Required

    Code indicating the date format, time format, or date and time format

    D8
    Date Expressed in Format CCYYMMDD
    DMG-02
    1251
    Dependent Birth Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    • DMG02 is the date of birth.
    DMG-03
    1068
    Dependent Gender Code
    Optional

    Code indicating the sex of the individual

    F
    Female
    M
    Male
    U
    Unknown
    INS
    2600

    Dependent Relationship

    OptionalMax use 1

    To provide benefit information on insured entities

    Usage notes
    • 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.
    Example
    INS-01
    1073
    Insured Indicator
    Required

    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
    INS-02
    1069
    Individual Relationship Code
    Required

    Code indicating the relationship between two individuals or entities

    01
    Spouse
    19
    Child
    G8
    Other Relationship
    INS-17
    1470
    Birth Sequence Number
    Optional
    Min 1Max 9

    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.).
    2000E Patient Event Level Loop
    OptionalMax >1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-02
    734
    Hierarchical Parent ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    TRN
    0200

    Patient Event Tracking Number

    OptionalMax use 3

    To uniquely identify a transaction to an application

    Usage notes
    • 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.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    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.

    TRN-02
    127
    Patient Event Trace Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • TRN02 provides unique identification for the transaction.
    TRN-03
    509
    Trace Assigning Entity Identifier
    Required
    Min 10Max 10

    A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

    • TRN03 identifies an organization.
    Usage notes
    • 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.
    TRN-04
    127
    Trace Assigning Entity Additional Identifier
    Optional
    Min 1Max 50

    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.
    AAA
    0300

    Patient Event Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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.

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    UM
    0400

    Health Care Services Review Information

    RequiredMax use 1

    To specify health care services review information

    Usage notes
    • Identifies the type of health care services review.
    Example
    UM-01
    1525
    Request Category Code
    Required

    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.

    UM-02
    1322
    Certification Type Code
    Required

    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.

    UM-03
    1365
    Service Type Code
    Optional

    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
    UM-04
    C023
    Health Care Service Location Information
    To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered
    Usage notes

    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.

    C023-01
    1331
    Facility Type Code
    Required
    Min 1Max 2

    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.

    Usage notes
    • Use to indicate a facility code value from the code source referenced in UM04-2.
    C023-02
    1332
    Facility Code Qualifier
    Required

    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
    UM-06
    1338
    Level of Service Code
    Optional

    Code specifying the level of service rendered

    03
    Emergency
    E
    Elective
    U
    Urgent
    HCR
    0500

    Health Care Services Review

    OptionalMax use 1

    To specify the outcome of a health care services review

    Usage notes
    • 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.
    Example
    HCR-01
    306
    Action Code
    Required

    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.

    HCR-02
    127
    Review Identification Number
    Optional

    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.
    A1
    Certified in total
    A6
    Modified
    HCR-03
    1271
    Review Decision Reason Code
    Optional
    Max use 5
    Min 1Max 30

    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
    Usage notes
    • This data element is a repeating data element and can be repeated the maximum number allowed by the standard in this implementation guide.
    HCR-04
    1073
    Second Surgical Opinion Indicator
    Optional

    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
    REF
    0600

    Administrative Reference Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • 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.
    Example
    Variants (all may be used)
    REFPrevious Review Authorization Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    NT
    Administrator's Reference Number
    REF-02
    127
    Administrative Reference Number
    Required

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    A3
    Not Certified
    A4
    Pended
    CT
    Contact payer
    REF
    0600

    Previous Review Authorization Number

    OptionalMax use 1

    To specify identifying information

    Usage notes
    • 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.
    Example
    Variants (all may be used)
    REFAdministrative Reference Number
    REF-01
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    BB
    Authorization Number
    REF-02
    127
    Previous Review Authorization Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    DTP
    0700

    Accident Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    439
    Accident
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Accident Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Admission Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    435
    Admission
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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.

    DTP-03
    1251
    Proposed or Actual Admission Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Certification Effective Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    007
    Effective
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Certification Effective Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Certification Expiration Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    036
    Expiration
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Certification Expiration Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Certification Issue Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    102
    Issue
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Certification Issue Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Discharge Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    096
    Discharge
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Proposed or Actual Discharge Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Estimated Date of Birth

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    ABC
    Estimated Date of Birth
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Estimated Birth Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Event Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    AAH
    Event
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Proposed or Actual Event Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Last Menstrual Period Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    484
    Last Menstrual Period
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Last Menstrual Period Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    DTP
    0700

    Onset of Current Symptoms or Illness Date

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    DTP-01
    374
    Date Time Qualifier
    Required

    Code specifying type of date or time, or both date and time

    431
    Onset of Current Symptoms or Illness
    DTP-02
    1250
    Date Time Period Format Qualifier
    Required

    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
    DTP-03
    1251
    Onset Date
    Required
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI
    0800

    Patient Diagnosis

    OptionalMax use 1

    To supply information related to the delivery of health care

    Usage notes
    • 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.

    Example
    HI-01
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-02
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-03
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-04
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-05
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-06
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-07
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-08
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-09
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-10
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-11
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HI-12
    C022
    Health Care Code Information
    To send health care codes and their associated dates, amounts and quantities
    Usage notes

    Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.

    If either Date Time Period Format Qualifier (C022-03) or Diagnosis Date (C022-04) is present, then the other is required
    C022-01
    1270
    Diagnosis Type Code
    Required

    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
    C022-02
    1271
    Diagnosis Code
    Required
    Min 1Max 30

    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.
    C022-03
    1250
    Date Time Period Format Qualifier
    Optional

    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
    C022-04
    1251
    Diagnosis Date
    Optional
    Min 1Max 35

    Expression of a date, a time, or range of dates, times or dates and times

    HSD
    0900

    Health Care Services Delivery

    OptionalMax use 1

    To specify the delivery pattern of health care services

    Usage notes
    • 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".

    Example
    If either Quantity Qualifier (HSD-01) or Service Unit Count (HSD-02) is present, then the other is required
    If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required
    HSD-01
    673
    Quantity Qualifier
    Optional

    Code specifying the type of quantity

    DY
    Days
    FL
    Units
    HS
    Hours
    MN
    Month
    VS
    Visits
    HSD-02
    380
    Service Unit Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    HSD-03
    355
    Unit or Basis for Measurement Code
    Optional

    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
    HSD-04
    1167
    Sample Selection Modulus
    Optional
    Min 1Max 6

    To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

    HSD-05
    615
    Time Period Qualifier
    Optional

    Code defining periods

    6
    Hour
    7
    Day
    21
    Years
    26
    Episode
    27
    Visit
    34
    Month
    35
    Week
    HSD-06
    616
    Period Count
    Optional
    Min 1Max 3

    Total number of periods

    HSD-07
    678
    Delivery Frequency Code
    Optional

    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)
    HSD-08
    679
    Delivery Pattern Time Code
    Optional

    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)
    CL1
    1100

    Institutional Claim Code

    OptionalMax use 1

    To supply information specific to hospital claims

    Usage notes
    • Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
    Example
    CL1-01
    1315
    Admission Type Code
    Optional
    Min 1Max 1

    Code indicating the priority of this admission

    CL1-02
    1314
    Admission Source Code
    Optional
    Min 1Max 1

    Code indicating the source of this admission

    CL1-03
    1352
    Patient Status Code
    Optional
    Min 1Max 2

    Code indicating patient status as of the "statement covers through date"

    CR1
    1200

    Ambulance Transport Information

    OptionalMax use 1

    To supply information related to the ambulance service rendered to a patient

    Usage notes
    • 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.
    Example
    If either Unit or Basis for Measurement Code (CR1-05) or Transport Distance (CR1-06) is present, then the other is required
    CR1-03
    1316
    Ambulance Transport Code
    Required

    Code indicating the type of ambulance transport

    I
    Initial Trip
    R
    Return Trip
    T
    Transfer Trip
    X
    Round Trip
    CR1-05
    355
    Unit or Basis for Measurement Code
    Optional

    Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

    DH
    Miles
    DK
    Kilometers
    CR1-06
    380
    Transport Distance
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR106 is the distance traveled during transport.
    CR2
    1300

    Spinal Manipulation Service Information

    OptionalMax use 1

    To supply information related to the chiropractic service rendered to a patient

    Usage notes
    • 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.
    Example
    If either Treatment Series Number (CR2-01) or Treatment Count (CR2-02) is present, then the other is required
    If Subluxation Level Code (CR2-04) is present, then Subluxation Level Code (CR2-03) is required
    CR2-01
    609
    Treatment Series Number
    Optional
    Min 1Max 9

    Occurrence counter

    • CR201 is the number this treatment is in the series.
    CR2-02
    380
    Treatment Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR202 is the total number of treatments in the series.
    CR2-03
    1367
    Subluxation Level Code
    Optional

    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
    CR2-04
    1367
    Subluxation Level Code
    Optional

    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
    CR5
    1400

    Home Oxygen Therapy Information

    OptionalMax use 1

    To supply information regarding certification of medical necessity for home oxygen therapy

    Usage notes
    • Required when used by the UMO to authorize specific usage of home oxygen therapy. If not required by this implementation guide, do not send.
    Example
    CR5-03
    1348
    Oxygen Equipment Type Code
    Optional

    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
    CR5-04
    1348
    Oxygen Equipment Type Code
    Optional

    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
    CR5-06
    380
    Oxygen Flow Rate
    Required
    Min 1Max 15

    Numeric value of quantity

    • CR506 is the oxygen flow rate in liters per minute.
    CR5-07
    380
    Daily Oxygen Use Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR507 is the number of times per day the patient must use oxygen.
    CR5-08
    380
    Oxygen Use Period Hour Count
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR508 is the number of hours per period of oxygen use.
    CR5-09
    352
    Respiratory Therapist Order Text
    Optional
    Min 1Max 80

    A free-form description to clarify the related data elements and their content

    • CR509 is the special orders for the respiratory therapist.
    CR5-16
    380
    Portable Oxygen System Flow Rate
    Optional
    Min 1Max 15

    Numeric value of quantity

    • CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
    CR5-17
    1382
    Oxygen Delivery System Code
    Required

    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
    CR5-18
    1348
    Oxygen Equipment Type Code
    Optional

    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
    CR6
    1500

    Home Health Care Information

    OptionalMax use 1

    To supply information related to the certification of a home health care patient

    Usage notes
    • Required when used by the UMO to render a medical decision. If not required by this implementation guide, do not send.
    Example
    If either Date Time Period Format Qualifier (CR6-03) or Home Health Certification Period (CR6-04) is present, then the other is required
    CR6-01
    923
    Prognosis Code
    Required

    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
    CR6-02
    373
    Home Health Start Date
    Required
    CCYYMMDD format

    Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

    • CR602 is the date covered home health services began.
    CR6-03
    1250
    Date Time Period Format Qualifier
    Optional

    Code indicating the date format, time format, or date and time format

    RD8
    Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
    CR6-04
    1251
    Home Health Certification Period
    Optional
    Min 1Max 35

    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.
    CR6-07
    1073
    Medicare Coverage Indicator
    Required

    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
    CR6-08
    1322
    Certification Type Code
    Required

    Code indicating the type of certification

    Usage notes
    • 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
    PWK
    1550

    Additional Patient Information

    OptionalMax use 10

    To identify the type or transmission or both of paperwork or supporting information

    Usage notes
    • 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.

    Example
    If either Identification Code Qualifier (PWK-05) or Attachment Control Number (PWK-06) is present, then the other is required
    PWK-01
    755
    Attachment Report Type Code
    Required

    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
    PWK-02
    756
    Report Transmission Code
    Required

    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
    E-Mail
    FX
    By Fax
    VO
    Voice

    Use this for voicemail or phone communication.

    PWK-05
    66
    Identification Code Qualifier
    Optional

    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
    PWK-06
    67
    Attachment Control Number
    Optional
    Min 2Max 80

    Code identifying a party or other code

    PWK-07
    352
    Attachment Description
    Optional
    Min 1Max 80

    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.
    MSG
    1600

    Message Text

    OptionalMax use 1

    To provide a free-form format that allows the transmission of text information

    Usage notes
    • 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.
    Example
    MSG-01
    933
    Free Form Message Text
    Required
    Min 1Max 264

    Free-form message text

    2010EB Additional Patient Information Contact Name Loop
    OptionalMax 1
    NM1
    1700

    Additional Patient Information Contact Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • 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.

    Example
    If either Identification Code Qualifier (NM1-08) or Response Contact Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    Code identifying an organizational entity, a physical location, property or an individual

    L5
    Contact
    NM1-02
    1065
    Entity Type Qualifier
    Required

    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
    NM1-03
    1035
    Response Contact Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Response Contact First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Response Contact Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-07
    1039
    Response Contact Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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.

    NM1-09
    67
    Response Contact Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    N3
    2000

    Additional Patient Information Contact Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • 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.
    Example
    N3-01
    166
    Response Contact Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the requester's address.
    N3-02
    166
    Response Contact Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Additional Patient Information Contact City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • 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.
    Example
    Only one of Additional Patient Information Contact State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Additional Patient Information Contact City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Additional Patient Information Contact State Code
    Optional
    Min 2Max 2

    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.
    N4-03
    116
    Additional Patient Information Contact Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    PER
    2200

    Additional Patient Information Contact Information

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    If either Communication Number Qualifier (PER-03) or Response Contact Communication Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Response Contact Communication Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Response Contact Communication Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    IC
    Information Contact
    PER-02
    93
    Response Contact Name
    Optional
    Min 1Max 60

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Optional

    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.

    PER-04
    364
    Response Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension
    FX
    Facsimile
    TE
    Telephone
    PER-06
    364
    Response Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    EX
    Telephone Extension
    FX
    Facsimile
    TE
    Telephone
    PER-08
    364
    Response Contact Communication Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    2010EA Patient Event Provider Name Loop
    OptionalMax 14
    NM1
    1700

    Patient Event Provider Name

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • 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.
    Example
    If either Identification Code Qualifier (NM1-08) or Patient Event Provider Identifier (NM1-09) is present, then the other is required
    NM1-01
    98
    Entity Identifier Code
    Required

    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
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    1
    Person
    2
    Non-Person Entity
    NM1-03
    1035
    Patient Event Provider Last or Organization Name
    Optional
    Min 1Max 60

    Individual last name or organizational name

    NM1-04
    1036
    Patient Event Provider First Name
    Optional
    Min 1Max 35

    Individual first name

    NM1-05
    1037
    Patient Event Provider Middle Name
    Optional
    Min 1Max 25

    Individual middle name or initial

    NM1-06
    1038
    Patient Event Provider Name Prefix
    Optional
    Min 1Max 10

    Prefix to individual name

    NM1-07
    1039
    Patient Event Provider Name Suffix
    Optional
    Min 1Max 10

    Suffix to individual name

    NM1-08
    66
    Identification Code Qualifier
    Optional

    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.

    NM1-09
    67
    Patient Event Provider Identifier
    Optional
    Min 2Max 80

    Code identifying a party or other code

    REF
    1800

    Patient Event Provider Supplemental Identification

    OptionalMax use 7

    To specify identifying information

    Usage notes
    • 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.
    Example
    At least one of Patient Event Provider Supplemental Identifier (REF-02) or License Number State Code (REF-03) is required
    REF-01
    128
    Reference Identification Qualifier
    Required

    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.

    REF-02
    127
    Patient Event Provider Supplemental Identifier
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    REF-03
    352
    License Number State Code
    Optional
    Min 1Max 80

    A free-form description to clarify the related data elements and their content

    N3
    2000

    Patient Event Provider Address

    OptionalMax use 1

    To specify the location of the named party

    Usage notes
    • 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.
    Example
    N3-01
    166
    Patient Event Provider Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the service provider's address.
    N3-02
    166
    Patient Event Provider Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Patient Event Provider City, State, ZIP Code

    OptionalMax use 1

    To specify the geographic place of the named party

    Usage notes
    • 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.
    Example
    Only one of Patient Event Provider State Code (N4-02) or Country Subdivision Code (N4-07) may be present
    If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
    N4-01
    19
    Patient Event Provider City Name
    Required
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Patient Event Provider State Code
    Optional
    Min 2Max 2

    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.
    N4-03
    116
    Patient Event Provider Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    N4-04
    26
    Country Code
    Optional
    Min 2Max 3

    Code identifying the country

    Usage notes
    • Use the alpha-2 country codes from Part 1 of ISO 3166.
    N4-07
    1715
    Country Subdivision Code
    Optional
    Min 1Max 3

    Code identifying the country subdivision

    Usage notes
    • Use the country subdivision codes from Part 2 of ISO 3166.
    PER
    2200

    Provider Contact Information

    OptionalMax use 1

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

    Usage notes
    • 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.
    Example
    If either Communication Number Qualifier (PER-03) or Patient Event Provider Contact Communications Number (PER-04) is present, then the other is required
    If either Communication Number Qualifier (PER-05) or Patient Event Provider Contact Communications Number (PER-06) is present, then the other is required
    If either Communication Number Qualifier (PER-07) or Patient Event Provider Contact Communications Number (PER-08) is present, then the other is required
    PER-01
    366
    Contact Function Code
    Required

    Code identifying the major duty or responsibility of the person or group named

    IC
    Information Contact
    PER-02
    93
    Patient Event Provider Contact Name
    Optional
    Min 1Max 60

    Free-form name

    PER-03
    365
    Communication Number Qualifier
    Optional

    Code identifying the type of communication number

    EM
    Electronic Mail
    FX
    Facsimile
    TE
    Telephone
    UR
    Uniform Resource Locator (URL)
    PER-04
    364
    Patient Event Provider Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-05
    365
    Communication Number Qualifier
    Optional

    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)
    PER-06
    364
    Patient Event Provider Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    PER-07
    365
    Communication Number Qualifier
    Optional

    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)
    PER-08
    364
    Patient Event Provider Contact Communications Number
    Optional
    Min 1Max 256

    Complete communications number including country or area code when applicable

    AAA
    2300

    Patient Event Provider Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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
    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    PRV
    2400

    Patient Event Provider Information

    OptionalMax use 1

    To specify the identifying characteristics of a provider

    Usage notes
    • Required when used by the UMO to identify the provider. If not required by this implementation guide, do not send.
    Example
    PRV-01
    1221
    Provider Code
    Required

    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.

    PRV-02
    128
    Reference Identification Qualifier
    Required

    Code qualifying the Reference Identification

    PXC
    Health Care Provider Taxonomy Code
    PRV-03
    127
    Provider Taxonomy Code
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    2010EC Patient Event Transport Information Loop
    OptionalMax 5
    NM1
    1700

    Patient Event Transport Information

    RequiredMax use 1

    To supply the full name of an individual or organizational entity

    Usage notes
    • Required when used by the UMO to authorize specific transport services. If not required by this implementation guide, do not send.
    Example
    NM1-01
    98
    Entity Identifier Code
    Required

    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
    NM1-02
    1065
    Entity Type Qualifier
    Required

    Code qualifying the type of entity

    • NM102 qualifies NM103.
    2
    Non-Person Entity
    NM1-03
    1035
    Patient Event Transport Location Name
    Required
    Min 1Max 60

    Individual last name or organizational name

    N3
    2000

    Patient Event Transport Location Address

    RequiredMax use 1

    To specify the location of the named party

    Example
    N3-01
    166
    Patient Event Transport Location Address Line
    Required
    Min 1Max 55

    Address information

    Usage notes
    • Use this element for the first line of the transport location address.
    N3-02
    166
    Patient Event Transport Location Address Line
    Optional
    Min 1Max 55

    Address information

    N4
    2100

    Patient Event Transport Location City/State/ZIP Code

    RequiredMax use 1

    To specify the geographic place of the named party

    Example
    N4-01
    19
    Patient Event Transport Location City Name
    Optional
    Min 2Max 30

    Free-form text for city name

    • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
    N4-02
    156
    Patient Event Transport Location State or Province Code
    Optional
    Min 2Max 2

    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.
    N4-03
    116
    Patient Event Transport Location Postal Zone or ZIP Code
    Optional
    Min 3Max 15

    Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

    AAA
    2300

    Patient Event Transport Location Request Validation

    OptionalMax use 9

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

    Usage notes
    • 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.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    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 transport information.

    33
    Input Errors

    Use for input errors not covered by another reject reason code.

    47
    Invalid/Missing Provider State

    Use to code to indicate that the transport location state is invalid or missing.

    97
    Invalid or Missing Provider Address

    Use this code to indicate that the transport location address is invalid or missing.

    AAA-04
    889
    Follow-up Action Code
    Required

    Code identifying follow-up actions allowed

    C
    Please Correct and Resubmit
    N
    Resubmission Not Allowed
    2000F Service Level Loop
    OptionalMax >1
    HL
    0100

    Hierarchical Level

    RequiredMax use 1

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

    Example
    HL-01
    628
    Hierarchical ID Number
    Required
    Min 1Max 12

    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.
    HL-02
    734
    Hierarchical Parent ID Number
    Required
    Min 1Max 12

    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.
    HL-03
    735
    Hierarchical Level Code
    Required

    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.
    SS
    Services
    HL-04
    736
    Hierarchical Child Code
    Optional

    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.
    TRN
    0200

    Service Trace Number

    OptionalMax use 3

    To uniquely identify a transaction to an application

    Usage notes
    • 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 service in the response for tracking purposes. If not required by this implementation guide, do not send.
    Example
    TRN-01
    481
    Trace Type Code
    Required

    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.

    TRN-02
    127
    Service Trace Number
    Required
    Min 1Max 50

    Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

    • TRN02 provides unique identification for the transaction.
    TRN-03
    509
    Trace Assigning Entity Identifier
    Required
    Min 10Max 10

    A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

    • TRN03 identifies an organization.
    Usage notes
    • 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.
    TRN-04
    127
    Trace Assigning Entity Additional Identifier
    Optional
    Min 1Max 50

    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.
    AAA
    0300

    Service Request Validation

    OptionalMax use 9

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

    Usage notes
    • If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
    • If Loop 2000F is present in the response, either the AAA segment or the HCR segment must be returned.
    • Required when the request is not valid at this level. If not required by this implementation guide, do not send.
    Example
    AAA-01
    1073
    Valid Request Indicator
    Required

    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
    AAA-03
    901
    Reject Reason Code
    Required

    Code assigned by issuer to identify reason for rejection

    15
    Required application data missing