X12 278 Health Care Services Review Information - Review (X217)
This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.
Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HI
- Health Care Services Review Information (278)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X217
- ANSI ASC X12 Health Care Services Review Information (278) for requests for review and responses to such requests through May 2006
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- Use this segment to indicate the start of a health care services review request transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based utilization management request.
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- 278
- Health Care Services Review Information
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The Transaction Set Control Numbers in ST02 and SE02 must be identical. The number is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the number 0001 and increment from there. The number also aids in error resolution research. Use the corresponding value in SE02 for this transaction set.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X217
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- 0007
- Information Source, Information Receiver, Subscriber, Dependent, Event, Services
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier must be returned in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of 278 request transactions are required to return the Submitter Transaction Identifier in their 278 response if one is submitted.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
Code specifying the type of transaction
- RU
- Medical Services Reservation
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Utilization Management Organization (UMO) Name
To supply the full name of an individual or organizational entity
- This segment identifies the source of information. In the case of a request transaction, the source of information would normally be the payer or utilization review organization making the decision on the request.
Code identifying an organizational entity, a physical location, property or an individual
- X3
- Utilization Management Organization
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Individual first name
Individual middle name or initial
Suffix to individual name
Code designating the system/method of code structure used for Identification Code (67)
- PI
- Payor Identification
Use when UMO is a payer and XV is not used.
Code identifying a party or other code
- 06111
- UHC Payer ID
- 87726
- UHC Payer ID
- 061118515
- Oxford Payer ID
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Requester Name
To supply the full name of an individual or organizational entity
- This segment identifies the receiver of information. In the case of a request transaction, the receiver would normally be the entity who will ultimately be receiving the decision.
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
Use when the requester is an individual provider.
- FA
- Facility
Use when the requester is a facility, such as a clinic or hospital.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
The name of the provider or facility submitting the request is required.
Code designating the system/method of code structure used for Identification Code (67)
NPI is required
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it;
If not required by this implementation guide, do not send.
Requester Supplemental Identification
To specify identifying information
- Required prior to the mandated HIPAA National Provider Identifier (NPI) implementation date when an identification number other than the NPI is necessary for the UMO to identify the provider;
OR
Required after the mandated NPI implementation date, when the entity is a non-health care provider, and an identifier is necessary for the UMO to identify the entity.
If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EI
- Employer's Identification Number
Facility Tax Identification Number (TIN).
Not used if NM108 = 24. - ZH
- Carrier Assigned Reference Number
Unique provider identifier assigned by payer (MPIN).
Required when necessary to provide the requester/provider ID as assigned by the UMO identified in Loop 2000A. If not required, do not send.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Must be padded with leading zeros to equal 9 digits
Requester Address
To specify the location of the named party
- Use to identify a specific location when the requester has multiple locations and authority varies based on location.
- Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
Requester City, State, ZIP Code
To specify the geographic place of the named party
- Required when necessary to identify the requester by location. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Requester Contact Information
To identify a person or office to whom administrative communications should be directed
- Required when the UMO must direct requests for additional information to a specific requester contact, electronic mail, facsimile, or telephone number. If not required by this implementation guide, do not send.
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Free-form name
Free form contact name. This should be the name of an individual at the submitting provider/facility that UnitedHealthcare can contact if there are questions or more information is needed about this admission notification. If an individual contact name cannot be provided, please populate this field with the facility or provider name from NM103.
Code identifying the type of communication number
At least one contact phone number is required.
- TE
- Telephone
Complete communications number including country or area code when applicable
Phone number - Format 10 digits no punctuation or spaces
Code identifying the type of communication number
If applicable
- EX
- Telephone Extension
Complete communications number including country or area code when applicable
Extension (numeric only), if applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Must not contain any characters used as delimiters in this transaction.
Complete communications number including country or area code when applicable
Requester Provider Information
To specify the identifying characteristics of a provider
- Required when needed to indicate the requester's role in the care of the patient and the requesting provider's specialty. If not required by this implementation guide, do not send.
Code identifying the type of provider
- AD
- Admitting
- AS
- Assistant Surgeon
- AT
- Attending
- CO
- Consulting
- CV
- Covering
- OP
- Operating
- OR
- Ordering
- OT
- Other Physician
- PC
- Primary Care Physician
- PE
- Performing
- RF
- Referring
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Name
To supply the full name of an individual or organizational entity
- This segment conveys the name and identification number of the subscriber (who may also be the patient).
- The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02) - Refer to Section 2.2.2.1 Identifying the Patient for specific information on how to identify an individual to a UMO.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Subscriber Last name (Required)
Individual first name
Subscriber First name. Required if member has a legal first name. If member has only 1 legal name, send member name in Last Name and do not populate first name.
Code designating the system/method of code structure used for Identification Code (67)
- MI
- Member Identification Number
The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms:
Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.
Code identifying a party or other code
Member Identification preferably from UnitedHealth insurance card.
Subscriber Supplemental Identification
To specify identifying information
- Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.
- The primary identifier is the Member Identification Number in the NM1 segment.
- 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.
- If the requester values this segment with the Patient Account Number (REF01="EJ") on the request, the UMO is required to return the same value in this segment on the response.
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).
- 6P
- Group Number
preferred
- HJ
- Identity Card Number
Referral only
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
Referral only
- N6
- Plan Network Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Subscriber Address
To specify the location of the named party
- Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the subscriber is the patient and the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Subscriber Demographic Information
To supply demographic information
- Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
- Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
Gender Code is required.
- F
- Female
- M
- Male
- U
- Unknown
Subscriber Relationship
To provide benefit information on insured entities
- Required when the subscriber's role in the military is necessary to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- Y
- Yes
Code indicating the relationship between two individuals or entities
- 18
- Self
Code showing the general employment status of an employee/claimant
- Use to qualify the patient's relationship to the military.
- AO
- Active Military - Overseas
- AU
- Active Military - USA
- DI
- Deceased
- PV
- Previous
- RU
- Retired Military - USA
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Dependent Name
To supply the full name of an individual or organizational entity
- This segment conveys the name of the dependent who is the patient.
- The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02) - Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Code identifying an organizational entity, a physical location, property or an individual
- QC
- Patient
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
Individual last name or organizational name
Dependent’s Last Name
Individual first name
Dependent’s First Name - Required if dependent has a legal first name. If dependent has only 1 legal name, send dependent name in Last Name and do not populate first name.
Dependent Supplemental Identification
To specify identifying information
- Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
- If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.
- Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- EJ
- Patient Account Number
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.
- SY
- Social Security Number
The social security number may not be used for Medicare.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Dependent Address
To specify the location of the named party
- Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Dependent City, State, ZIP Code
To specify the geographic place of the named party
- Required when the current address of the patient is used to determine the appropriate location or network of service. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Dependent Demographic Information
To supply demographic information
- Required when birth date is needed to identify the patient or when gender information is required to determine medical necessity. If not required by this implementation guide, do not send.
- Refer to Section 1.12.2 Identifying the Patient for specific information on how to identify an individual to a UMO.
Code indicating the date format, time format, or date and time format
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
Code indicating the sex of the individual
Gender Code is required
- F
- Female
- M
- Male
- U
- Unknown
Dependent Relationship
To provide benefit information on insured entities
- Required when patient relationship to insured or birth sequence is needed by the UMO to determine the appropriate benefit/level of care. If not required by this implementation guide, do not send.
- This segment may be used to further identify the patient. Examples include identifying a patient in a multiple birth or differentiating dependents with the same name.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- G8
- Other Relationship
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- EV
- Event
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Patient Event Tracking Number
To uniquely identify a transaction to an application
- Required when the requester needs to assign a unique trace number to the patient event request. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
- This enables the requester to
- uniquely identify this patient event request
- trace the request
- match the response to the request
- reference this request in any associated attachments containing additional patient information related to this patient event request.
- If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.
- Each trace number provided in the TRN segment at this level on the request must be returned by the UMO in the TRN segment at the corresponding level of the response.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
- The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
Health Care Services Review Information
To specify health care services review information
- This segment identifies the type of health care services review request.
Code indicating a type of request
- AR
- Admission Review
Required if requesting an admission to a facility.
- HS
- Health Services Review
Required if requesting a review of services related to an episode of care.
- SC
- Specialty Care Review
Required if requesting a referral to a specialty provider.
Code indicating the type of certification
If submitting a change to a previously submitted and approved authorization, please provide the administrative Reference Number from the original authorization request in the following REF segment. This is required when submitting a revision or update.)
- I
- Initial
- S
- Revised
Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.
Code identifying the classification of service
- 1
- Medical Care
- 2
- Surgical
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 12
- Durable Medical Equipment Purchase
- 14
- Renal Supplies in the Home
- 18
- Durable Medical Equipment Rental
- 33
- Chiropractic
- 37
- Dental Accident
- 45
- Hospice
- 54
- Long Term Care
- 56
- Medically Related Transportation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 78
- Chemotherapy
- 88
- Pharmacy
- 93
- Podiatry
- A9
- Rehabilitation
- AD
- Occupational Therapy
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AL
- Vision (Optometry)
- NI
- Neonatal Intensive Care
- PT
- Physical Therapy
Required when UM04 is not valued at 2000F. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Code identifying where services were, or may be, performed; the first and second positions of the Uniform Bill Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
- Use to indicate a facility code value from the code source referenced in UM04-2.
- 11
- if UM04-2=A: Hospital Inpatient including Medicare Part A if UM04-2=B: Office
- 13
- if UM04-2=A: Hospital Outpatient if UM04-2=B: Home
- 21
- if UM04-2=A: Skilled Nursing Facility (SNF) Inpatient including Medicare Part A if UM04-2=B: Hospital Outpatient
- 61
- if UM04-2=B: Rehab Facility Comprehensive Inpatient
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
Required when the patient's condition is accident or employment related. If not required by this implementation guide, do not send.
Code identifying an accompanying cause of an illness, injury or an accident
- Always use this data element if the related cause is an auto accident.
- AA
- Auto Accident
- AP
- Another Party Responsible
- EM
- Employment
Code identifying an accompanying cause of an illness, injury or an accident
- AP
- Another Party Responsible
- EM
- Employment
Code identifying an accompanying cause of an illness, injury or an accident
- AP
- Another Party Responsible
Code (Standard State/Province) as defined by appropriate government agency
- C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
Code specifying the level of service rendered
- 03
- Emergency
- E
- Elective
- U
- Urgent
Code indicating current health condition of the individual
- 1
- Acute
- 2
- Stable
- 3
- Chronic
- 4
- Systemic
- 5
- Localized
- 6
- Mild Disease
- 7
- Normal, Healthy
- 8
- Severe Systemic disease
- 9
- Severe Systemic Disease that is a Constant Threat to Life
- E
- Excellent
- F
- Fair
- G
- Good
- P
- Poor
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
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
- The Release of Information response is limited to the information carried in this service review.
- M
- The Provider has Limited or Restricted Ability to Release Data Related to a Claim
For professional service, this value is only used when state or federal laws supersede the HIPAA privacy rule by requiring that the provider collect a signature and the patient is either not present or physically unable to sign at the time the provider submits the request.
- Y
- Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Code indicating the reason why a request was delayed
- 1
- Proof of Eligibility Unknown or Unavailable
- 2
- Litigation
- 3
- Authorization Delays
- 4
- Delay in Certifying Provider
- 7
- Third Party Processing Delay
- 8
- Delay in Eligibility Determination
- 10
- Administration Delay in the Prior Approval Process
- 11
- Other
- 15
- Natural Disaster
- 16
- Lack of Information
- 17
- No response to initial request
Previous Review Authorization Number
To specify identifying information
- This is the authorization number assigned by the UMO to the original service review outcome associated with this service review. This is not the trace number assigned by the requester.
- Required when submitting an additional health care services review request associated with a request already processed by the UMO. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- BB
- Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Previous Review Administrative Reference Number
To specify identifying information
- Required when submitting a follow-up to a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- NT
- Administrator's Reference Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Accident Date
To specify any or all of a date, a time, or a time period
- Required when the patient's condition is accident related and the date of the accident is known. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 439
- Accident
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Last Menstrual Period Date
To specify any or all of a date, a time, or a time period
- Required when the certification is pregnancy related. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 484
- Last Menstrual Period
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Estimated Date of Birth
To specify any or all of a date, a time, or a time period
- Required when the certification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- ABC
- Estimated Date of Birth
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Onset of Current Symptoms or Illness Date
To specify any or all of a date, a time, or a time period
- Required when the date of onset of the patient's condition is different from the diagnosis date, and not accident or pregnancy related. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 431
- Onset of Current Symptoms or Illness
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Event Date
To specify any or all of a date, a time, or a time period
- Required when the proposed or actual date or range of dates of this patient event are known and UM01 does not equal AR. If not required by this implementation guide, do not send.
- If UM01 = AR use Admit Date.
Code specifying type of date or time, or both date and time
- AAH
- Event
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Admission Date
To specify any or all of a date, a time, or a time period
- Required when requesting an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 435
- Admission
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Use this for the range of dates when admission can occur. Use the HSD segment for the length of stay.;
Expression of a date, a time, or range of dates, times or dates and times
Discharge Date
To specify any or all of a date, a time, or a time period
- Required when requesting an admission review (UM01 = "AR") and the proposed or actual date of discharge from a facility is known. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 096
- Discharge
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Patient Diagnosis
To supply information related to the delivery of health care
- Required when known by the requester to convey diagnosis information. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ICD-10 is to be used with DATE OF SERVICE AS OF OCT 1, 2015 - In order to assign appropriate resources to the case; UnitedHealthcare needs to
understand why the patient is being treated. A Principal or Admitting diagnosis code is required. Please send it in this HI segment.
- 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
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.
ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ICD-10 to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- ABJ
- International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis
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.
ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
CD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Additional diagnosis information may be provided if available.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
ICD-10 code to be used with DATE OF SERVICE AS OF OCT 1, 2015 Format ANX.XXXX
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Required when there are additional diagnoses to communicate. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- APR
- International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
- DR
- Diagnosis Related Group (DRG)
- PR
- International Classification of Diseases Clinical Modification (ICD-9-CM) Patient's Reason for Visit
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Code indicating the date format, time format, or date and time format
- C022-03 is the date format that will appear in C022-04.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
Health Care Services Delivery
To specify the delivery pattern of health care services
- 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".
- Required when requesting services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
Code specifying the type of quantity
- DY
- Days
- FL
- Units
- HS
- Hours
- MN
- Month
- VS
- Visits
Numeric value of quantity
- If this is a request for an extension to an existing certification (UM02 = 4), then HSD02 represents the number of visits by which the certification is extended. If this is a request to revise an existing certification (UM02 = S), then HSD02 represents the new total.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DA
- Days
- MO
- Months
- WK
- Week
To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes
Code defining periods
- 6
- Hour
- 7
- Day
- 21
- Years
- 26
- Episode
- 27
- Visit
- 34
- Month
- 35
- Week
Code which specifies the routine shipments, deliveries, or calendar pattern
- 1
- 1st Week of the Month
- 2
- 2nd Week of the Month
- 3
- 3rd Week of the Month
- 4
- 4th Week of the Month
- 5
- 5th Week of the Month
- 6
- 1st & 3rd Weeks of the Month
- 7
- 2nd & 4th Weeks of the Month
- 8
- 1st Working Day of Period
- 9
- Last Working Day of Period
- A
- Monday through Friday
- B
- Monday through Saturday
- C
- Monday through Sunday
- D
- Monday
- E
- Tuesday
- F
- Wednesday
- G
- Thursday
- H
- Friday
- J
- Saturday
- K
- Sunday
- L
- Monday through Thursday
- M
- Immediately
- N
- As Directed
- O
- Daily Mon. through Fri.
- P
- 1/2 Mon. & 1/2 Thurs.
- Q
- 1/2 Tues. & 1/2 Thurs.
- R
- 1/2 Wed. & 1/2 Fri.
- S
- Once Anytime Mon. through Fri.
- SA
- Sunday, Monday, Thursday, Friday, Saturday
- SB
- Tuesday through Saturday
- SC
- Sunday, Wednesday, Thursday, Friday, Saturday
- SD
- Monday, Wednesday, Thursday, Friday, Saturday
- SG
- Tuesday through Friday
- SL
- Monday, Tuesday and Thursday
- SP
- Monday, Tuesday and Friday
- SX
- Wednesday and Thursday
- SY
- Monday, Wednesday and Thursday
- SZ
- Tuesday, Thursday and Friday
- T
- 1/2 Tue. & 1/2 Fri.
- U
- 1/2 Mon. & 1/2 Wed.
- V
- 1/3 Mon., 1/3 Wed., 1/3 Fri.
- W
- Whenever Necessary
- X
- 1/2 By Wed., Bal. By Fri.
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Code which specifies the time for routine shipments or deliveries
- A
- 1st Shift (Normal Working Hours)
- B
- 2nd Shift
- C
- 3rd Shift
- D
- A.M.
- E
- P.M.
- F
- As Directed
- G
- Any Shift
- Y
- None (Also Used to Cancel or Override a Previous Pattern)
Ambulance Certification Information
To supply information on conditions
- Required when health care services review is requesting ambulance certification. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 07
- Ambulance Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 01
- Patient was admitted to a hospital
- 02
- Patient was bed confined before the ambulance service
- 03
- Patient was bed confined after the ambulance service
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 5A
- Treatment is rendered related to the terminal illness
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 9D
- Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
- 41
- Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
- 43
- Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
- 60
- Transportation Was To the Nearest Facility
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Chiropractic Certification Information
To supply information on conditions
- Required when health care services review is requesting chiropractic certification. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 08
- Chiropractic Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 11
- Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
- 12
- Patient is confined to a bed or chair
- 14
- Ambulation is Impaired and Walking Aid is Used for Mobility
- 24
- Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
- 25
- Item has been prescribed as part of a planned regimen of treatment in patient home
- 27
- Patient or a care-giver has been instructed in use of equipment
- 30
- Without the equipment, the patient would require surgery
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Durable Medical Equipment Information
To supply information on conditions
- Required when health care services is requesting durable medical equipment. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 09
- Durable Medical Equipment Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 01
- Patient was admitted to a hospital
- 02
- Patient was bed confined before the ambulance service
- 03
- Patient was bed confined after the ambulance service
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 06
- Patient was transported in an emergency situation
- 07
- Patient had to be physically restrained
- 08
- Patient had visible hemorrhaging
- 09
- Ambulance service was medically necessary
- 9D
- Lack of Appropriate Facility within Reasonable Distance to Treat Patient in the Event of Complications
- 9H
- Patient Requires Intensive IV Therapy
- 9J
- Patient Requires Protective Isolation
- 9K
- Patient Requires Frequent Monitoring
- 10
- Patient is ambulatory
- 11
- Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
- 12
- Patient is confined to a bed or chair
- 13
- Patient is Confined to a Room or an Area Without Bathroom Facilities
- 14
- Ambulation is Impaired and Walking Aid is Used for Mobility
- 15
- Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
- 16
- Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
- 17
- Patient's Ability to Breathe is Severely Impaired
- 18
- Patient condition requires frequent and/or immediate changes in body positions
- 19
- Patient can operate controls
- 20
- Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
- 21
- Patient owns equipment
- 22
- Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
- 23
- Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
- 24
- Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
- 25
- Item has been prescribed as part of a planned regimen of treatment in patient home
- 26
- Patient is highly susceptible to decubitus ulcers
- 27
- Patient or a care-giver has been instructed in use of equipment
- 29
- A 6-7 hour nocturnal study documents 30 episodes of apnea each lasting more than 10 seconds
- 30
- Without the equipment, the patient would require surgery
- 31
- Patient has had a total knee replacement
- 32
- Patient has intractable lymphedema of the extremities
- 33
- Patient is in a nursing home
- 35
- This Feeding is the Only Form of Nutritional Intake for This Patient
- 37
- Oxygen delivery equipment is stationary
- 38
- Certification signed by the physician is on file at the supplier's office
- 40
- Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
- 41
- Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
- 42
- Patient Requires Leg Elevation for Edema or Body Alignment
- 43
- Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
- 44
- Patient Requires Reclining Function of a Wheelchair
- 45
- Patient is Unable to Operate a Wheelchair Manually
- 46
- Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
- 58
- Durable Medical Equipment (DME) Purchased New
- 59
- Durable Medical Equipment (DME) Is Under Warranty
- 60
- Transportation Was To the Nearest Facility
- IH
- Independent at Home
- LB
- Legally Blind
- SL
- Speech Limitations
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Oxygen Therapy Certification Information
To supply information on conditions
- Required when health care services review is requesting oxygen therapy certification. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 11
- Oxygen Therapy Certification
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 5A
- Treatment is rendered related to the terminal illness
- 06
- Patient was transported in an emergency situation
- 9J
- Patient Requires Protective Isolation
- 9K
- Patient Requires Frequent Monitoring
- 16
- Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
- 17
- Patient's Ability to Breathe is Severely Impaired
- 25
- Item has been prescribed as part of a planned regimen of treatment in patient home
- 33
- Patient is in a nursing home
- 37
- Oxygen delivery equipment is stationary
- 39
- Patient Has Mobilizing Respiratory Tract Secretions
- DY
- Dyspnea with Minimal Exertion
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Functional Limitations Information
To supply information on conditions
- Required when the assessing provider has defined function limitation for the patient. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 75
- Functional Limitations
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 02
- Patient was bed confined before the ambulance service
- 03
- Patient was bed confined after the ambulance service
- 04
- Patient was moved by stretcher
- 05
- Patient was unconscious or in shock
- 5A
- Treatment is rendered related to the terminal illness
- 06
- Patient was transported in an emergency situation
- 9E
- Sudden Onset of Disorientation
- 9F
- Sudden Onset of Severe, Incapacitating Pain
- 9H
- Patient Requires Intensive IV Therapy
- 11
- Ambulation is Impaired and Walking Aid is Used for Therapy or Mobility
- 12
- Patient is confined to a bed or chair
- 14
- Ambulation is Impaired and Walking Aid is Used for Mobility
- 15
- Patient Condition Requires Positioning of the Body or Attachments Which Would Not be Feasible With the Use of an Ordinary Bed
- 16
- Patient needs a trapeze bar to sit up due to respiratory condition or change body positions for other medical reasons
- 17
- Patient's Ability to Breathe is Severely Impaired
- 18
- Patient condition requires frequent and/or immediate changes in body positions
- 19
- Patient can operate controls
- 20
- Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
- 21
- Patient owns equipment
- 22
- Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
- 23
- Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
- 24
- Patient has an orthopedic impairment requiring traction equipment which prevents ambulation during period of use
- 25
- Item has been prescribed as part of a planned regimen of treatment in patient home
- 26
- Patient is highly susceptible to decubitus ulcers
- 27
- Patient or a care-giver has been instructed in use of equipment
- 28
- Patient has poor diabetic control
- 30
- Without the equipment, the patient would require surgery
- 31
- Patient has had a total knee replacement
- 32
- Patient has intractable lymphedema of the extremities
- 35
- This Feeding is the Only Form of Nutritional Intake for This Patient
- 37
- Oxygen delivery equipment is stationary
- 39
- Patient Has Mobilizing Respiratory Tract Secretions
- 40
- Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
- 41
- Patient or Caregiver is Unable to Propel or Lift a Standard Weight Wheelchair
- 42
- Patient Requires Leg Elevation for Edema or Body Alignment
- 43
- Patient Weight or Usage Needs Necessitate a Heavy Duty Wheelchair
- 44
- Patient Requires Reclining Function of a Wheelchair
- 45
- Patient is Unable to Operate a Wheelchair Manually
- 46
- Patient or Caregiver Requires Side Transfer into Wheelchair, Commode or Other
- 68
- Severe
- 69
- Moderate
- AA
- Amputation
- AL
- Ambulation Limitations
- BL
- Bowel Limitations, Bladder Limitations, or both (Incontinence)
- BPD
- Beneficiary is Partially Dependent
- BTD
- Beneficiary is Totally Dependent
- CA
- Cane Required
- CB
- Complete Bedrest
- CNJ
- Cumulative Injury
- CO
- Contracture
- DY
- Dyspnea with Minimal Exertion
- EL
- Endurance Limitations
- EP
- Exercises Prescribed
- HL
- Hearing Limitations
- LB
- Legally Blind
- LE
- Lethargic
- OL
- Other Limitation
- PA
- Paralysis
- PW
- Partial Weight Bearing
- SL
- Speech Limitations
- TNJ
- Traumatic Injury
- WA
- Walker Required
- WR
- Wheelchair Required
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Activities Permitted Information
To supply information on conditions
- Required when the assessing provider has defined activities permitted for the patient. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 76
- Activities Permitted
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 10
- Patient is ambulatory
- 13
- Patient is Confined to a Room or an Area Without Bathroom Facilities
- 19
- Patient can operate controls
- 21
- Patient owns equipment
- 22
- Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
- 27
- Patient or a care-giver has been instructed in use of equipment
- 31
- Patient has had a total knee replacement
- 40
- Patient or Caregiver is Capable of Using the Equipment Without Technical or Professional Supervision
- BR
- Bedrest BRP (Bathroom Privileges)
- CA
- Cane Required
- CB
- Complete Bedrest
- CR
- Crutches Required
- EL
- Endurance Limitations
- EP
- Exercises Prescribed
- IH
- Independent at Home
- NR
- No Restrictions
- PA
- Paralysis
- PW
- Partial Weight Bearing
- TR
- Transfer to Bed, or Chair, or Both
- UT
- Up as Tolerated
- WA
- Walker Required
- WR
- Wheelchair Required
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Mental Status Information
To supply information on conditions
- Required when the patient mental status is relevant to the health care services review. If not required by this implementation guide, do not send.
Specifies the situation or category to which the code applies
- CRC01 qualifies CRC03 through CRC07.
- 77
- Mental Status
Code indicating a Yes or No condition or response
- CRC02 is a Certification Condition Code applies indicator. A "Y" value indicates the condition codes in CRC03 through CRC07 apply; an "N" value indicates the condition codes in CRC03 through CRC07 do not apply.
- N
- No
- Y
- Yes
Code indicating a condition
- 01
- Patient was admitted to a hospital
- 05
- Patient was unconscious or in shock
- 5A
- Treatment is rendered related to the terminal illness
- 07
- Patient had to be physically restrained
- 9E
- Sudden Onset of Disorientation
- 9F
- Sudden Onset of Severe, Incapacitating Pain
- 9J
- Patient Requires Protective Isolation
- 9K
- Patient Requires Frequent Monitoring
- 13
- Patient is Confined to a Room or an Area Without Bathroom Facilities
- 20
- Siderails Are to be Attached to a Hospital Bed Owned by the Beneficiary
- 22
- Mattress or Siderails are Being Used with Prescribed Medically Necessary Hospital Bed Owned by the Beneficiary
- 23
- Patient Needs Lift to Get In or Out of Bed or to Assist in Transfer from Bed to Wheelchair
- 26
- Patient is highly susceptible to decubitus ulcers
- 33
- Patient is in a nursing home
- 34
- Patient is conscious
- 68
- Severe
- 69
- Moderate
- AG
- Agitated
- BPD
- Beneficiary is Partially Dependent
- BTD
- Beneficiary is Totally Dependent
- CB
- Complete Bedrest
- CM
- Comatose
- DI
- Disoriented
- DP
- Depressed
- FO
- Forgetful
- HO
- Hostile
- LE
- Lethargic
- MC
- Other Mental Condition
- OT
- Oriented
- UN
- Uncooperative
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Code indicating a condition
- Use codes listed in CRC03.
Institutional Claim Code
To supply information specific to hospital claims
- Required when requesting certification for admission (UM01 = AR) to a facility. If not required by this implementation guide, do not send.
Code indicating patient status as of the "statement covers through date"
Code specifying the status of a nursing home resident at the time of service
- 1
- Transferred to Intermediate Care Facility - Mentally Retarded (ICF-MR)
- 2
- Newly Admitted
- 3
- Newly Eligible
- 4
- No Longer Eligible
- 5
- Still a Resident
- 6
- Temporary Absence - Hospital
- 7
- Temporary Absence - Other
- 8
- Transferred to Intermediate Care Facility - Level II (ICF II)
- 9
- Other
Ambulance Transport Information
To supply information related to the ambulance service rendered to a patient
- Required when health care services review is for non-emergency transportation services. If not required by this implementation guide, do not send.
- When the CR1 segment is used, then Loop 2010EB is required.
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- KG
- Kilogram
- LB
- Pound
Numeric value of weight
- CR102 is the weight of the patient at time of transport.
Code indicating the type of ambulance transport
- I
- Initial Trip
- R
- Return Trip
- T
- Transfer Trip
- X
- Round Trip
Code indicating the reason for ambulance transport
- A
- Patient was transported to nearest facility for care of symptoms, complaints, or both
- B
- Patient was transported for the benefit of a preferred physician
- C
- Patient was transported for the nearness of family members
- D
- Patient was transported for the care of a specialist or for availability of specialized equipment
- E
- Patient Transferred to Rehabilitation Facility
- F
- Patient Transferred to Residential Facility
Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken
- DH
- Miles
- DK
- Kilometers
Numeric value of quantity
- CR106 is the distance traveled during transport.
A free-form description to clarify the related data elements and their content
- CR109 is the purpose for the round trip ambulance service.
A free-form description to clarify the related data elements and their content
- CR110 is the purpose for the usage of a stretcher during ambulance service.
Spinal Manipulation Service Information
To supply information related to the chiropractic service rendered to a patient
- Required when requesting certification for spinal manipulation services (UM01=HS) when the patient's condition or treatment involves subluxation. If not required by this implementation guide, do not send.
Occurrence counter
- CR201 is the number this treatment is in the series.
Numeric value of quantity
- CR202 is the total number of treatments in the series.
Code identifying the specific level of subluxation
- When both CR203 and CR204 are present, CR203 is the beginning level of subluxation and CR204 is the ending level of subluxation.
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Code identifying the specific level of subluxation
- C1
- Cervical 1
- C2
- Cervical 2
- C3
- Cervical 3
- C4
- Cervical 4
- C5
- Cervical 5
- C6
- Cervical 6
- C7
- Cervical 7
- CO
- Coccyx
- IL
- Ilium
- L1
- Lumbar 1
- L2
- Lumbar 2
- L3
- Lumbar 3
- L4
- Lumbar 4
- L5
- Lumbar 5
- OC
- Occiput
- SA
- Sacrum
- T1
- Thoracic 1
- T10
- Thoracic 10
- T11
- Thoracic 11
- T12
- Thoracic 12
- T2
- Thoracic 2
- T3
- Thoracic 3
- T4
- Thoracic 4
- T5
- Thoracic 5
- T6
- Thoracic 6
- T7
- Thoracic 7
- T8
- Thoracic 8
- T9
- Thoracic 9
Code indicating the nature of a patient's condition
- A
- Acute Condition
- C
- Chronic Condition
- D
- Non-acute
- E
- Non-Life Threatening
- F
- Routine
- G
- Symptomatic
- M
- Acute Manifestation of a Chronic Condition
Code indicating a Yes or No condition or response
- CR209 is complication indicator. A "Y" value indicates a complicated condition; an "N" value indicates an uncomplicated condition.
- N
- No
- Y
- Yes
A free-form description to clarify the related data elements and their content
- CR210 is a description of the patient's condition.
A free-form description to clarify the related data elements and their content
- CR211 is an additional description of the patient's condition.
Code indicating a Yes or No condition or response
- CR212 is X-rays availability indicator. A "Y" value indicates X-rays are maintained and available for carrier review; an "N" value indicates X-rays are not maintained and available for carrier review.
- N
- No
- Y
- Yes
Home Oxygen Therapy Information
To supply information regarding certification of medical necessity for home oxygen therapy
- Required when requesting initial, extended, or revised certification of;home oxygen therapy. If not required by this implementation guide, do not send.
- Use the UM segment data element UM02 instead of CR501 to specify the;Certification Type Code.
- Use the HSD segment instead of CR502 to specify the treatment period.
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
A free-form description to clarify the related data elements and their content
- CR505 is the reason for equipment.
Numeric value of quantity
- CR506 is the oxygen flow rate in liters per minute.
Numeric value of quantity
- CR507 is the number of times per day the patient must use oxygen.
Numeric value of quantity
- CR508 is the number of hours per period of oxygen use.
A free-form description to clarify the related data elements and their content
- CR509 is the special orders for the respiratory therapist.
Numeric value of quantity
- CR510 is the arterial blood gas.
- Either CR510 or CR511 is required.
Numeric value of quantity
- CR511 is the oxygen saturation.
- Either CR510 or CR511 is required.
Code indicating the conditions under which a patient was tested
- E
- Exercising
- N
- No special conditions for test
- O
- On oxygen
- R
- At rest on room air
- S
- Sleeping
- W
- Walking
- X
- Other
Code indicating the findings of oxygen tests performed on a patient
- 1
- Dependent edema suggesting congestive heart failure
- 2
- "P" Pulmonale on Electrocardiogram (EKG)
- 3
- Erythrocythemia with a hematocrit greater than 56 percent
Code indicating the findings of oxygen tests performed on a patient
- 1
- Dependent edema suggesting congestive heart failure
- 2
- "P" Pulmonale on Electrocardiogram (EKG)
- 3
- Erythrocythemia with a hematocrit greater than 56 percent
Code indicating the findings of oxygen tests performed on a patient
- 1
- Dependent edema suggesting congestive heart failure
- 2
- "P" Pulmonale on Electrocardiogram (EKG)
- 3
- Erythrocythemia with a hematocrit greater than 56 percent
Numeric value of quantity
- CR516 is the oxygen flow rate for a portable oxygen system in liters per minute.
Code to indicate if a particular form of delivery was prescribed
- A
- Nasal Cannula
- B
- Oxygen Conserving Device
- C
- Oxygen Conserving Device with Oxygen Pulse System
- D
- Oxygen Conserving Device with Reservoir System
- E
- Transtracheal Catheter
Code indicating the specific type of equipment being prescribed for the delivery of oxygen
- A
- Concentrator
- B
- Liquid Stationary
- C
- Gaseous Stationary
- D
- Liquid Portable
- E
- Gaseous Portable
- O
- Other
Home Health Care Information
To supply information related to the certification of a home health care patient
- Required when requesting for certification of home health care, private duty nursing, or services by a nurses' agency. If not required by this implementation guide, do not send.
- Requests for home health care must include a principal diagnosis (HI01=BK) and principal diagnosis date in the HI segment in Loop 2000E, Patient Event.
Code indicating physician's prognosis for the patient
- 1
- Poor
- 2
- Guarded
- 3
- Fair
- 4
- Good
- 5
- Very Good
- 6
- Excellent
- 7
- Less than 6 Months to Live
- 8
- Terminal
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR602 is the date covered home health services began.
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- CR604 is the certification period covered by this plan of treatment.
Code indicating a Yes or No condition or response
- CR607 indicates if the patient is covered by Medicare. A "Y" value indicates the patient is covered by Medicare; an "N" value indicates patient is not covered by Medicare.
- W
- Not Applicable
Code indicating the type of certification
- This element must have the same value as UM02.
- 1
- Appeal - Immediate
Use this value only for appeals of review decisions where the level of service required is emergency or urgent.
- 2
- Appeal - Standard
Use this value for appeals of review decisions where the level of service required is not emergency or urgent.
- 3
- Cancel
- 4
- Extension
Indicates that this is an extension request to a prior approved service.
- 6
- Verification
This code is used to request the UMO to reconsider a previously denied referral or certification request.
- I
- Initial
- R
- Renewal
Indicates that this is a request to renew a prior approved service.
- S
- Revised
Use if the requester is revising the specifics of a certification for which services have not been rendered.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR609 is the date that the surgery identified in CR611 was performed.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- CR610 qualifies CR611.
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
Because the AMA's CPT codes are also level 1 HCPCS codes, they are reported under HC.
- ID
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
Code value for describing a medical condition or procedure
- CR611 is the surgical procedure most relevant to the care being rendered.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR612 is the date the agency received the verbal orders from the physician for start of care.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR613 is the date that the patient was last seen by the physician.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- CR614 is the date of the home health agency's most recent contact with the physician.
Code indicating the date format, time format, or date and time format
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- CR616 is the date range of the most recent inpatient stay.
Code identifying the location where patient is receiving medical treatment
- CR617 indicates the type of facility from which the patient was most recently discharged.
- A
- Acute Care Facility
- B
- Boarding Home
- C
- Hospice
- D
- Intermediate Care Facility
- E
- Long-term or Extended Care Facility
- F
- Not Specified
- G
- Nursing Home
- H
- Sub-acute Care Facility
- L
- Other Location
- M
- Rehabilitation Facility
- O
- Outpatient Facility
- P
- Private Home
- R
- Residential Treatment Facility
- S
- Skilled Nursing Home
- T
- Rest Home
Additional Patient Information
To identify the type or transmission or both of paperwork or supporting information
- Required when needed to report missing teeth on requests for dental services, or if the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or all the services requested and the 278 request (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
- This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number in PWK06 would be referenced in the electronic attachment.
- The requester can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the UMO (or appropriate entity). Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.
Refer to Section 2.5 for more information on using this PWK segment.
Code indicating the title or contents of a document, report or supporting item
- 03
- Report Justifying Treatment Beyond Utilization Guidelines
- 04
- Drugs Administered
- 05
- Treatment Diagnosis
- 06
- Initial Assessment
- 07
- Functional Goals
Expected outcomes of rehabilitative services.
- 08
- Plan of Treatment
- 09
- Progress Report
- 10
- Continued Treatment
- 11
- Chemical Analysis
- 13
- Certified Test Report
- 15
- Justification for Admission
- 21
- Recovery Plan
- 48
- Social Security Benefit Letter
- 55
- Rental Agreement
Use for medical or dental equipment rental.
- 59
- Benefit Letter
- 77
- Support Data for Verification
- A3
- Allergies/Sensitivities Document
- A4
- Autopsy Report
- AM
- Ambulance Certification
Information to support necessity of ambulance trip.
- AS
- Admission Summary
A brief patient summary; it lists the patient's chief complaints and the reasons for admitting the patient to the hospital.
- AT
- Purchase Order Attachment
Use for purchase of medical or dental equipment.
- B2
- Prescription
- B3
- Physician Order
- BR
- Benchmark Testing Results
- BS
- Baseline
- BT
- Blanket Test Results
- CB
- Chiropractic Justification
Lists the reasons chiropractic is just and appropriate treatment.
- CK
- Consent Form(s)
- D2
- Drug Profile Document
- DA
- Dental Models
- DB
- Durable Medical Equipment Prescription
- DG
- Diagnostic Report
- DJ
- Discharge Monitoring Report
- DS
- Discharge Summary
- FM
- Family Medical History Document
- HC
- Health Certificate
- HR
- Health Clinic Records
- I5
- Immunization Record
- IR
- State School Immunization Records
- LA
- Laboratory Results
- M1
- Medical Record Attachment
- NN
- Nursing Notes
- OB
- Operative Note
- OC
- Oxygen Content Averaging Report
- OD
- Orders and Treatments Document
- OE
- Objective Physical Examination (including vital signs) Document
- OX
- Oxygen Therapy Certification
- P4
- Pathology Report
- P5
- Patient Medical History Document
- P6
- Periodontal Charts
Required when using the PWK segment to provide missing teeth information.
- P7
- Periodontal Reports
- PE
- Parenteral or Enteral Certification
- PN
- Physical Therapy Notes
- PO
- Prosthetics or Orthotic Certification
- PQ
- Paramedical Results
- PY
- Physician's Report
- PZ
- Physical Therapy Certification
- QC
- Cause and Corrective Action Report
- QR
- Quality Report
- RB
- Radiology Films
- RR
- Radiology Reports
- RT
- Report of Tests and Analysis Report
- RX
- Renewable Oxygen Content Averaging Report
- SG
- Symptoms Document
- V5
- Death Notification
- XP
- Photographs
Code defining timing, transmission method or format by which reports are to be sent
- AA
- Available on Request at Provider Site
Required when using the PWK segment to provide missing teeth information.
This means that the paperwork is not being sent with the request at this time. Instead, it is available to the UMO (or appropriate entity) on request.
- BM
- By Mail
- EL
- Electronically Only
Use to indicate that the attachment is being transmitted in a separate X12 functional group.
- EM
- FX
- By Fax
- VO
- Voice
Use this for voicemail or phone communication.
Code designating the system/method of code structure used for Identification Code (67)
- PWK05 and PWK06 may be used to identify the addressee by a code number.
- AC
- Attachment Control Number
Code identifying a party or other code
- The requester can use it when PWK02 equals "AA" if the requester wants to send a document control number for an attachment remaining at the Provider's office.
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.
- To report tooth number(s) for missing teeth, use a variable length format. Allocate two (2) bytes for each missing tooth. When reporting tooth numbers 1 through 9, zero fill the first byte so the field will be 01, 02, etc. When reporting primary dentition (A through P), pad the second byte with a space.
Message Text
To provide a free-form format that allows the transmission of text information
- Required when needed to transmit a text message to the UMO about the patient event. If not required by this implementation guide, do not send.
- Do not use the MSG segment to relay information that you can send using codified information in existing data elements. If you need to use the MSG segment, you should approach X12N with data maintenance to solve the business need without the use of the MSG segment.
Patient Event Provider Name
To supply the full name of an individual or organizational entity
- If Loop 2000F is not valued, this segment conveys the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient for this patient event.
- If Loop 2000F is valued, the providers identified in this Loop 2010EA apply to all the services identified in Loop 2000F unless Loop 2010F is valued. Providers identified in Loop 2010F override the providers identified in Loop 2010EA for that service only.
- Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued or when loop 2000F is valued and at least one occurrence of loop 2000F does not contain a 2010F loop. If not required by this implementation guide, do not send.
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
Do not use if the entity identified in 2010B is the referring provider.
- FA
- Facility
- G3
- Clinic
- P3
- Primary Care Provider
- QB
- Purchase Service Provider
- QV
- Group Practice
- SJ
- Service Provider
Code qualifying the type of entity
- NM102 qualifies NM103.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
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 submitter.
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.
Patient Event Provider Supplemental Information
To specify identifying information
- Use the NM1 Segment for the primary identifier.
- Required on or after the mandated implementation date for the HIPAA National Provider Identifier (NPI) when the provider is not a specialty entity and the NPI is not reported in NM109 of this loop and another identifier is available to the submitter.
OR
Required prior to the mandated NPI implementation date when an additional identification number to the NPI provided in NM109 of this loop is necessary for the UMO to identify the patient event provider.
OR
Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider.
If not required by this implementation guide, do not send.
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 may not be used for Medicare. Not used if NM108 = 34.
- ZH
- Carrier Assigned Reference Number
Use when the requestor has not been assigned an NPI, or NPI is not mandated for use and the UMO identified in loop 2010A has assigned its own identifier for this provider.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
A free-form description to clarify the related data elements and their content
Patient Event Provider Address
To specify the location of the named party
- Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Patient Event Provider City, State, ZIP Code
To specify the geographic place of the named party
- Required when the provider has multiple locations to identify the specific location for this patient event. If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Patient Event Provider Contact Information
To identify a person or office to whom administrative communications should be directed
- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and telephone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
- Required when needed to identify a contact name and/or communications number for the provider. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
Code identifying the major duty or responsibility of the person or group named
- IC
- Information Contact
Free-form name
- Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1). If not required, do not send.
Code identifying the type of communication number
- EM
- Electronic Mail
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Code identifying the type of communication number
- EM
- Electronic Mail
- EX
- Telephone Extension
When used, the value following this code is the extension for the preceding communications contact number.
- FX
- Facsimile
- TE
- Telephone
- UR
- Uniform Resource Locator (URL)
Complete communications number including country or area code when applicable
Patient Event Provider Information
To specify the identifying characteristics of a provider
- Required when request is for services of a specialist or specialty entity to indicate the provider's specialty. If not required by this implementation guide, may be provided a the sender's discretion but cannot be required by the receiver.
Code identifying the type of provider
- AD
- Admitting
Use only when NM101 = AAJ.
- AS
- Assistant Surgeon
Use only when NM101 = DD.
- AT
- Attending
Use only when NM101 = 71.
- OP
- Operating
Use only when NM101 = 72.
- OR
- Ordering
Use only when NM101 = DK.
- OT
- Other Physician
Use only when NM101 = 73.
- PC
- Primary Care Physician
Use only when NM101 = P3.
- PE
- Performing
Use only when NM101 = SJ.
- RF
- Referring
Use only when NM101 = DN.
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Patient Event Transport Information
To supply the full name of an individual or organizational entity
- Required when Health Care Service Review is requesting transport of the patient. If not required by this implementation guide, do not send.
- At least two iterations of this loop are necessary to indicate the pick up address, NM101 = PW, and the final scheduled destination, NM101 = FS.
- When the transport includes more than one destination, the following NM101 values are used to determine the sequence of stops:
a. ND is used to indicate the first stop
b. R3 is used to indicate the second stop
c. 45 is used to indicate the third stop
Code identifying an organizational entity, a physical location, property or an individual
- 45
- Drop-off Location
- FS
- Final Scheduled Destination
- ND
- Next Destination
- PW
- Pickup Address
- R3
- Next Scheduled Destination
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Individual last name or organizational name
Patient Event Transport Location Address
To specify the location of the named party
Patient Event Transport Location City/State/ZIP Code
To specify the geographic place of the named party
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Patient Event Other UMO Name
To supply the full name of an individual or organizational entity
- Required when Health Care Services Review has been denied by another UMO. If not required by this implementation guide, do not send.
Code identifying an organizational entity, a physical location, property or an individual
- 00
- Alternate Insurer
Use this code to indicate that the other UMO is commercial insurance.
- CA
- Carrier
Use this code to indicate that the other UMO is Medicare Part B.
- GG
- Intermediary
Use this code to indicate that the other UMO is Medicare Part A.
Code qualifying the type of entity
- NM102 qualifies NM103.
- 2
- Non-Person Entity
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Required when the Health Care Services Review was denied by other UMO for more than one reason. If not required by this implementation guide, do not send.
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Code qualifying the Reference Identification
- ZZ
- Mutually Defined
Use ZZ to indicate Health Care Service Review Decision Reason Code from Code Source 886.
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier