New: Drop-in replacement for Change Healthcare APIs

EDI 278 X217 - Health Care Services Review Information - Review

Functional Group HI

X12N Insurance Subcommittee

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.

Heading

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

   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.

2. 0200 · BHT · Beginning of Hierarchical Transaction · Max 1 · Mandatory

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

Detail

1. 2000A Loop Mandatory Repeat 1

   1. 0100 · HL · Utilization Management Organization (UMO) Level · Max 1 · Mandatory

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

      This segment indicates the information source hierarchical level. For a request transaction, this segment corresponds to the identification of the payer, HMO, or other utilization management organization who will be the source of the decision/response.

   2. 2010A Loop Mandatory Repeat 1

      1. 1700 · NM1 · Utilization Management Organization (UMO) Name · Max 1 · Mandatory

         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.

   3. 2000B Loop Mandatory Repeat 1

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

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

         This segment indicates the health care services review information receiver. For request transactions, this segment corresponds to the identification of the entity initiating the request for review.

      2. 2010B Loop Mandatory Repeat 1

         1. 1700 · NM1 · Requester Name · Max 1 · Mandatory

            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.

         2. 1800 · REF · Requester Supplemental Identification · Max 8 · Optional

            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.

         3. 2000 · N3 · Requester Address · Max 1 · Optional

            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.

         4. 2100 · N4 · Requester City, State, ZIP Code · Max 1 · Optional

            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.

         5. 2200 · PER · Requester Contact Information · Max 1 · Optional

            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.

         6. 2400 · PRV · Requester Provider Information · Max 1 · Optional

            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.

      3. 2000C Loop Mandatory Repeat 1

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

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

            This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.

         2. 2010C Loop Mandatory Repeat 1

            1. 1700 · NM1 · Subscriber Name · Max 1 · Mandatory

               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.

            2. 1800 · REF · Subscriber Supplemental Identification · Max 9 · Optional

               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.

            3. 2000 · N3 · Subscriber Address · Max 1 · Optional

               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.

            4. 2100 · N4 · Subscriber City, State, ZIP Code · Max 1 · Optional

               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.

            5. 2500 · DMG · Subscriber Demographic Information · Max 1 · Optional

               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.

            6. 2600 · INS · Subscriber Relationship · Max 1 · Optional

               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.

         3. 2000D Loop Optional Repeat 1

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

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

               If the patient has a unique member ID, use Loop 2000C to identify the patient.
               Required segments in this loop are required only when this loop is used.
               Required when the patient is someone other than the subscriber and the patient does not have a unique (different from the subscriber) member ID. If not required by this implementation guide, do not send.

            2. 2010D Loop Mandatory Repeat 1

               1. 1700 · NM1 · Dependent Name · Max 1 · Mandatory

                  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.

               2. 1800 · REF · Dependent Supplemental Identification · Max 3 · Optional

                  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.

               3. 2000 · N3 · Dependent Address · Max 1 · Optional

                  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.

               4. 2100 · N4 · Dependent City, State, ZIP Code · Max 1 · Optional

                  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.

               5. 2500 · DMG · Dependent Demographic Information · Max 1 · Optional

                  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.

               6. 2600 · INS · Dependent Relationship · Max 1 · Optional

                  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.

            3. 2000E Loop Mandatory Repeat 1

               1. 0100 · HL · Patient Event Level · Max 1 · Mandatory

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

                  Loop 2000E to provide information on the patient event associated with this health care services review.

               2. 0200 · TRN · Patient Event Tracking Number · Max 2 · Optional

                  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.

               3. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

                  To specify health care services review information

                  This segment identifies the type of health care services review request.

               4. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                  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.

               5. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                  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.

               6. 0700 · DTP · Accident Date · Max 1 · Optional

                  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.

               7. 0700 · DTP · Last Menstrual Period Date · Max 1 · Optional

                  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.

               8. 0700 · DTP · Estimated Date of Birth · Max 1 · Optional

                  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.

               9. 0700 · DTP · Onset of Current Symptoms or Illness Date · Max 1 · Optional

                  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.

               10. 0700 · DTP · Event Date · Max 1 · Optional

                   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.

               11. 0700 · DTP · Admission Date · Max 1 · Optional

                   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.

               12. 0700 · DTP · Discharge Date · Max 1 · Optional

                   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.

               13. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                   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.

               14. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                   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: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "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 HSD*VS*1*****SX*D~ 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.

               15. 1000 · CRC · Ambulance Certification Information · Max 1 · Optional

                   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.

               16. 1000 · CRC · Chiropractic Certification Information · Max 1 · Optional

                   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.

               17. 1000 · CRC · Durable Medical Equipment Information · Max 1 · Optional

                   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.

               18. 1000 · CRC · Oxygen Therapy Certification Information · Max 1 · Optional

                   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.

               19. 1000 · CRC · Functional Limitations Information · Max 1 · Optional

                   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.

               20. 1000 · CRC · Activities Permitted Information · Max 1 · Optional

                   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.

               21. 1000 · CRC · Mental Status Information · Max 1 · Optional

                   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.

               22. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                   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.

               23. 1200 · CR1 · Ambulance Transport Information · Max 1 · Optional

                   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.

               24. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                   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.

               25. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

                   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.

               26. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

                   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.

               27. 1550 · PWK · Additional Patient Information · Max 10 · Optional

                   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.

               28. 1600 · MSG · Message Text · Max 1 · Optional

                   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.

               29. 2010EA Loop Optional Repeat 14

                   1. 1700 · NM1 · Patient Event Provider Name · Max 1 · Mandatory

                      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.

                   2. 1800 · REF · Patient Event Provider Supplemental Information · Max 7 · Optional

                      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.

                   3. 2000 · N3 · Patient Event Provider Address · Max 1 · Optional

                      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.

                   4. 2100 · N4 · Patient Event Provider City, State, ZIP Code · Max 1 · Optional

                      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.

                   5. 2200 · PER · Patient Event Provider Contact Information · Max 1 · Optional

                      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.

                   6. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      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.

               30. 2010EB Loop Optional Repeat 5

                   1. 1700 · NM1 · Patient Event Transport Information · Max 1 · Mandatory

                      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

                   2. 2000 · N3 · Patient Event Transport Location Address · Max 1 · Mandatory

                      To specify the location of the named party

                   3. 2100 · N4 · Patient Event Transport Location City/State/ZIP Code · Max 1 · Mandatory

                      To specify the geographic place of the named party

               31. 2010EC Loop Optional Repeat 3

                   1. 1700 · NM1 · Patient Event Other UMO Name · Max 1 · Mandatory

                      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.

                   2. 1800 · REF · Other UMO Denial Reason · Max 1 · Mandatory

                      To specify identifying information

                   3. 2700 · DTP · Other UMO Denial Date · Max 1 · Mandatory

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

               32. 2000F Loop Optional Repeat >1

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

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

                      Required when specific services are associated with this patient event. If not required by this implementation guide, do not send.

                   2. 0200 · TRN · Service Trace Number · Max 2 · Optional

                      To uniquely identify a transaction to an application

                      Required when the requester needs to assign a unique trace number to the service line 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 service line request - trace the request - match the response to the request - reference this request in any associated attachments containing additional service information related to this service line 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.
                      If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.

                   3. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                      To specify health care services review information

                      Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

                   4. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                      To specify identifying information

                      This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
                      Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

                   5. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                      To specify identifying information

                      Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
                      This is the administrative 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.

                   6. 0700 · DTP · Service Date · Max 1 · Optional

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

                      Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.

                   7. 0810 · SV1 · Professional Service · Max 1 · Optional

                      To specify the service line item detail for a health care professional

                      Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.

                   8. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

                      To specify the service line item detail for a health care institution

                      Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

                   9. 0830 · SV3 · Dental Service · Max 1 · Optional

                      To specify the service line item detail for dental work

                      Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.

                   10. 0840 · TOO · Tooth Information · Max 32 · Optional

                       To identify a tooth by number and, if applicable, one or more tooth surfaces

                       Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.

                   11. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                       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: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "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 HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
                       Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.

                   12. 1550 · PWK · Additional Service Information · Max 10 · Optional

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

                       Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, 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.
                       Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
                       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.

                   13. 1600 · MSG · Message Text · Max 1 · Optional

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

                       Required when needed to transmit a message to the UMO about the service. 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.

                   14. 2010F Loop Optional Repeat 10

                       1. 1700 · NM1 · Service Provider Name · Max 1 · Mandatory

                          To supply the full name of an individual or organizational entity

                          Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
                          Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                          If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to provide services.

                       2. 1800 · REF · Service Provider Supplemental Identification · Max 8 · Optional

                          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 service provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service provider. If not required by this implementation guide, do not send.

                       3. 2000 · N3 · Service Provider Address · Max 1 · Optional

                          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.

                       4. 2100 · N4 · Service Provider City, State, ZIP Code · Max 1 · Optional

                          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.

                       5. 2200 · PER · Service Provider Contact Information · Max 1 · Optional

                          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.

                       6. 2400 · PRV · Service Provider Information · Max 1 · Optional

                          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.

         4. 2000E Loop Optional Repeat 1

            1. 0100 · HL · Patient Event Level · Max 1 · Mandatory

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

               Loop 2000E to provide information on the patient event associated with this health care services review.

            2. 0200 · TRN · Patient Event Tracking Number · Max 2 · Optional

               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.

            3. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

               To specify health care services review information

               This segment identifies the type of health care services review request.

            4. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

               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.

            5. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

               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.

            6. 0700 · DTP · Accident Date · Max 1 · Optional

               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.

            7. 0700 · DTP · Last Menstrual Period Date · Max 1 · Optional

               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.

            8. 0700 · DTP · Estimated Date of Birth · Max 1 · Optional

               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.

            9. 0700 · DTP · Onset of Current Symptoms or Illness Date · Max 1 · Optional

               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.

            10. 0700 · DTP · Event Date · Max 1 · Optional

                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.

            11. 0700 · DTP · Admission Date · Max 1 · Optional

                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.

            12. 0700 · DTP · Discharge Date · Max 1 · Optional

                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.

            13. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                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.

            14. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                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: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "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 HSD*VS*1*****SX*D~ 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.

            15. 1000 · CRC · Ambulance Certification Information · Max 1 · Optional

                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.

            16. 1000 · CRC · Chiropractic Certification Information · Max 1 · Optional

                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.

            17. 1000 · CRC · Durable Medical Equipment Information · Max 1 · Optional

                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.

            18. 1000 · CRC · Oxygen Therapy Certification Information · Max 1 · Optional

                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.

            19. 1000 · CRC · Functional Limitations Information · Max 1 · Optional

                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.

            20. 1000 · CRC · Activities Permitted Information · Max 1 · Optional

                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.

            21. 1000 · CRC · Mental Status Information · Max 1 · Optional

                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.

            22. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                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.

            23. 1200 · CR1 · Ambulance Transport Information · Max 1 · Optional

                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.

            24. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

                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.

            25. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

                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.

            26. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

                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.

            27. 1550 · PWK · Additional Patient Information · Max 10 · Optional

                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.

            28. 1600 · MSG · Message Text · Max 1 · Optional

                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.

            29. 2010EA Loop Optional Repeat 14

                1. 1700 · NM1 · Patient Event Provider Name · Max 1 · Mandatory

                   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.

                2. 1800 · REF · Patient Event Provider Supplemental Information · Max 7 · Optional

                   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.

                3. 2000 · N3 · Patient Event Provider Address · Max 1 · Optional

                   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.

                4. 2100 · N4 · Patient Event Provider City, State, ZIP Code · Max 1 · Optional

                   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.

                5. 2200 · PER · Patient Event Provider Contact Information · Max 1 · Optional

                   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.

                6. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                   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.

            30. 2010EB Loop Optional Repeat 5

                1. 1700 · NM1 · Patient Event Transport Information · Max 1 · Mandatory

                   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

                2. 2000 · N3 · Patient Event Transport Location Address · Max 1 · Mandatory

                   To specify the location of the named party

                3. 2100 · N4 · Patient Event Transport Location City/State/ZIP Code · Max 1 · Mandatory

                   To specify the geographic place of the named party

            31. 2010EC Loop Optional Repeat 3

                1. 1700 · NM1 · Patient Event Other UMO Name · Max 1 · Mandatory

                   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.

                2. 1800 · REF · Other UMO Denial Reason · Max 1 · Mandatory

                   To specify identifying information

                3. 2700 · DTP · Other UMO Denial Date · Max 1 · Mandatory

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

            32. 2000F Loop Optional Repeat >1

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

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

                   Required when specific services are associated with this patient event. If not required by this implementation guide, do not send.

                2. 0200 · TRN · Service Trace Number · Max 2 · Optional

                   To uniquely identify a transaction to an application

                   Required when the requester needs to assign a unique trace number to the service line 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 service line request - trace the request - match the response to the request - reference this request in any associated attachments containing additional service information related to this service line 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.
                   If the request contains more than one occurrence of Loop 2000F and the requester needs to uniquely identify each service level request this TRN segment is required in each Service loop.

                3. 0400 · UM · Health Care Services Review Information · Max 1 · Optional

                   To specify health care services review information

                   Required when the health care services review information for this service differs from the health care services review information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

                4. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                   To specify identifying information

                   This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.
                   Required when different from the Previous Review Authorization Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

                5. 0600 · REF · Previous Review Administrative Reference Number · Max 1 · Optional

                   To specify identifying information

                   Required when different from the Previous Review Administrative Reference Number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.
                   This is the administrative 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.

                6. 0700 · DTP · Service Date · Max 1 · Optional

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

                   Required when proposed or actual date or range of dates of service is different from the Patient Event Date in Loop 2000E. If not required by this implementation guide, do not send.

                7. 0810 · SV1 · Professional Service · Max 1 · Optional

                   To specify the service line item detail for a health care professional

                   Required when requesting a specific Professional Service. If not required by this implementation guide, do not send.

                8. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

                   To specify the service line item detail for a health care institution

                   Required when requesting a specific Institutional Service or requesting a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

                9. 0830 · SV3 · Dental Service · Max 1 · Optional

                   To specify the service line item detail for dental work

                   Required when requesting a specific Dental Service. If not required by this implementation guide, do not send.

                10. 0840 · TOO · Tooth Information · Max 32 · Optional

                    To identify a tooth by number and, if applicable, one or more tooth surfaces

                    Required when SV3 is valued and it is necessary to report tooth number and/or tooth surface. If not required by this implementation guide, do not send.

                11. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                    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: HSD*VS*1*DA*3*7*21~ = "One visit per every three days for 21 days". Another similar data string of HSD*VS*2*DA*4*7*20~ = "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 HSD*VS*1*****SX*D~ means "1 visit on Wednesday and Thursday morning".
                    Required when requesting services that have a specific pattern of delivery and the pattern of delivery or usage for this service is different from the pattern of delivery or usage (HSD) in the Patient Event (Loop 2000E). If not required by this implementation guide, do not send.

                12. 1550 · PWK · Additional Service Information · Max 10 · Optional

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

                    Required when the requester has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) requested in this Service loop, 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.
                    Additional documentation at the service level should apply to a specific service and/or all the services requested in this service loop.
                    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.

                13. 1600 · MSG · Message Text · Max 1 · Optional

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

                    Required when needed to transmit a message to the UMO about the service. 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.

                14. 2010F Loop Optional Repeat 10

                    1. 1700 · NM1 · Service Provider Name · Max 1 · Mandatory

                       To supply the full name of an individual or organizational entity

                       Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.
                       Required when requesting a service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
                       If this loop is not valued, loop 2010E is required to identify the service provider, specialist, or speciality entity to provide services.

                    2. 1800 · REF · Service Provider Supplemental Identification · Max 8 · Optional

                       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 service provider. OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the service provider. If not required by this implementation guide, do not send.

                    3. 2000 · N3 · Service Provider Address · Max 1 · Optional

                       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.

                    4. 2100 · N4 · Service Provider City, State, ZIP Code · Max 1 · Optional

                       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.

                    5. 2200 · PER · Service Provider Contact Information · Max 1 · Optional

                       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.

                    6. 2400 · PRV · Service Provider Information · Max 1 · Optional

                       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.

2. 2800 · SE · Transaction Set Trailer · Max 1 · Mandatory

   To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)