Health Care Services Review Information - Review (X217)

ST*278*0001*005010X217~
BHT*0007*13*A12345*20050502*1101~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*GARDENER*JAMES****XX*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*0~
TRN*1*111099*9012345678~
UM*SC*I*3*11>B*****Y~
HI*BF>41090>D8>20050430~
HSD*VS*1~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PER*IC**TE*4029993456~
SE*16*0001~


Example 1: Referral

ST*278*0001*005010X217~
BHT*0007*13*B56789*20050502*1430~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*WATSON*SUSAN****XX*98765432~
PER*IC**TE*4029993456~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*1~
TRN*1*97021001*9012345678~
UM*AR*I*2*21>B*****Y~
DTP*435*D8*20050516~
HI*BF>41090>D8>20050125~
HSD*DY*7~
CL1*2~
NM1*FA*2*MONTGOMERY HOSPITAL*****24*000012121~
N3*475 MAIN STREET~
N4*ANYTOWN*PA*19087~
HL*5*4*SS*0~
UM*HS*I*2~
DTP*472*D8*20050516~
SV2**HC>33510~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PRV*PE*PXC*203BS0133X~
SE*26*0001~


Example 2: Admission for Surgery

ST*278*0001*005010X217~
BHT*0007*13*YZZ345*20050502*1101~
HL*1**20*1~
NM1*X3*2*CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*FA*2*GENERAL HOSPITAL*****XX*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*MARY****MI*12345678901~
HL*4*3*EV*0~
TRN*1*YZZ099*9876543210~
UM*AR*I*A4*21>B**03***Y~
DTP*435*D8*20050505~
HI*BF>29603>D8>20050430~
HSD*DY*3~
CL1*1~
NM1*FA*2*GENERAL HOSPITAL*****46*987654321~
PER*IC**TE*4029993456~
NM1*71*1*JONES*MARCUS****24*453667654~
NM1*SJ*1*BROWN*JACOB****24*123454545~
SE*20*0001~

Example 3: Request for Behavioral Health Emergency Admission

ST*278*0001*005010X217~
BHT*0007*13*B56789*20050502*1430~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*WATSON*SUSAN****XX*98765432~
PER*IC**TE*4029993456~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*1~
UM*HS*I**12>B*****Y~
HI*BF>1831*BF>2630~
HSD*VS*3*WK**34*2~
CR6*1*20050502*RD8*20050502-20050801***W*I~
NM1*SJ*2*CARING HANDS HOME HEALTH AGENCY*****24*345678912~
HL*5*4*SS*0~
SV1*HC>G0154~
HL*6*4*SS*0~
SV1*HC>B4184~
SE*20*0001~

Example 4: Request for Home Health Care

ST*278*0001*005010X217~
BHT*0007*13*165932*20050502*1525~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*XYZ AMBULANCE SVC*****XX*7759621873~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
REF*1L*6532214A76~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*HS*I*56*41>B~
DTP*AAH*D8*20050510~
CRC*07*Y*09~
CR1***X*D*DH*27***TRIP FROM HOME TO OFFICE VISIT TO DIALYSIS TREATMENT AND BACK HOME~
NM1*PW*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
NM1*ND*2*DR. GARDNER OFFICE~
N3*1921 FULTON AVENUE~
N4*SACRAMENTO*CA*95624~
NM1*R3*2*XYZ DIALYSIS CENTER~
N3*7622 MORSETOWN ROAD~
N4*SACRAMENTO*CA*95826~
NM1*FS*2*HOME~
N3*8652 Starwood Lane~
N4*SACRAMENTO*CA*95826~
HL*5*4*SS*0~
SV1*HC>A0428>RX**UN*5~
HL*6*5*SS*0~
SV1*HC>A0428>PD**UN*8~
HL*7*6*SS*0~
SV1*HC>A0428>DR**UN*14~
SE*34*0001~

Example 5: Request for Non-emergency Transportation Service (Multi-destination Trip)

ST*278*0001*005010X217~
BHT*0007*13*5269367*20050502*2243*RU~
HL*1**20*1~
NM1*X3*2*ABC PAYER*****PI*06111~
HL*2*1*21*1~
NM1*1P*1*GARDNER*JAMES****XX*0010102364~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345689001~
DMG*D8*19580322*M~
HL*4*3*EV*1~
UM*IN*I*1*11>B~
HL*5*4*SS*0~
DTP*472*D8*20050510~
SV1*HC>99212**UN*1~
SE*15*0001~

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