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EDI 278 X216 - Health Care Services Review Information - Notification

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 notification or information copy transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based notification or information copy.

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 · Information Source Level · Max 1 · Mandatory

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

      This segment identifies the information source hierarchical level. For a notification transaction, this segment corresponds to the identification of the provider, payer, HMO, delegated entity, or other utilization management organization sending this information.

   2. 2010A Loop Mandatory Repeat 2

      1. 1700 · NM1 · Information Source Name · Max 1 · Mandatory

         To supply the full name of an individual or organizational entity

         The first occurrence of the NM1 loop is required and identifies the notification sender. In most cases, the sender is the same entity as the information source. The information source is the entity that determined the outcome of a health services review or the owner of the information.
         The second NM1 loop may be used when the sender is not the same entity as the information source, or if there is a need to identify another requesting entity that was neither the sender or the information source.

      2. 1800 · REF · Information Source Supplemental Identification · Max 9 · 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.
         Use the NM1 segment for the primary identifier.

      3. 2000 · N3 · Information Source Address · Max 1 · Optional

         To specify the location of the named party

         Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.
         Used to identify a specific location when the information source has multiple locations and his authority varies based on location.

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

         To specify the geographic place of the named party

         Required when necessary to identify the information source by location. If not required, by this implementation guide, do not send.

      5. 2200 · PER · Information Source 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 the information receiver must direct requests for follow up to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

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

         To specify the identifying characteristics of a provider

         PRV02 qualifies PRV03.
         Required when the information source is a provider and the provider's role in the care of the patient or the provider's specialty is needed to further identify the provider. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

   3. 2000B Loop Mandatory Repeat 1

      1. 0100 · HL · Information Receiver 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 notification information receiver.

      2. 2010B Loop Mandatory Repeat 1

         1. 1700 · NM1 · Information Receiver Name · Max 1 · Mandatory

            To supply the full name of an individual or organizational entity

            This segment identifies the receiver of information.

      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 1.11.2.1, Identifying the Subscriber/Patient.

            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 is 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 information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.

            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 was used to render a medical decision. If not required by this implementation guide, do not send.

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

               To provide benefit information on insured entities

               Required when the subscriber's role in the military was used 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

               This hierarchical loop is 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.
               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.

            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)

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

                  To specify identifying information

                  Required when needed to provide a supplemental identifier for the dependent. If not required by this implementation guide, do not send.
                  Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
                  If the information source values this segment with the Patient Account Number (REF01="EJ") on the notification, the notification receiver must return the same value in this segment on the acknowledgment response if one is returned.

               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 was used to render a medical decision. If not required by this implementation guide, do not send.

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

                  To provide benefit information on insured entities

                  Required when patient relationship to insured or birth sequence was used 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 identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.
                  Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only.

               2. 0200 · TRN · Patient Event Tracking Number · Max 3 · Optional

                  To uniquely identify a transaction to an application

                  Required when the information source needs to assign a unique trace number at the patient event level. 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 information receiver in the TRN segment at the corresponding level of the response.

               3. 0300 · AAA · Patient Event Request Validation · Max 9 · Optional

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

                  Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.
                  Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.

               4. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

                  To specify health care services review information

                  Required to identify the type of health care services in this notification.

               5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                  To specify the outcome of a health care services review

                  The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification, Review Decision Reason Code and Second Surgical Opinion Indicator data from the original decision maker is made available in the HCR segment to the information receiver.
                  Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.

               6. 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 event. This is not the trace number assigned by the requester.
                  Required when the certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

               7. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                  To specify identifying information

                  This is the administrative number assigned by the Information receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.
                  Required when this notification is related to an acknowledgment received from the information receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.

               8. 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.
                  The total number of DPT segments in the 2000E Loop cannot exceed 9.

               9. 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 notification is pregnancy related. If not required by this implementation guide, do not send.
                  The total number of DPT segments in the 2000E Loop cannot exceed 9.

               10. 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 notification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               11. 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.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               12. 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.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               13. 0700 · DTP · Admission Date · Max 1 · Optional

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

                   Required when identifying an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               14. 0700 · DTP · Discharge Date · Max 1 · Optional

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

                   Required when identifying 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.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               15. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                   Required when certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               16. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                   Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               17. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                   Required when the certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.
                   The total number of DPT segments in the 2000E Loop cannot exceed 9.

               18. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                   To supply information related to the delivery of health care

                   Required when identifying the diagnosis code at the event level. If not required by this implementation guide, do not send.

               19. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                   To specify the delivery pattern of health care services

                   Required when identifying services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
                   Report delivery patterns for specific services in the Service Level (Loop 2000F).
                   An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: 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".

               20. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                   To supply information specific to hospital claims

                   Required when identifying certifications for admissions (UM01 = AR) to a facility. If not required by this implementation guide, do not send.

               21. 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.

               22. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

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

                   Required when identifying 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.

               23. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

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

                   Required when identifying 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.

               24. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

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

                   Required when identifying 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.

               25. 1550 · PWK · Additional Patient Information · Max 10 · Optional

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

                   This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number inPWK06 would be referenced in the electronic attachment.
                   Required when needed to identify missing teeth for dental services, or to identify 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.
                   The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

               26. 1600 · MSG · Message Text · Max 1 · Optional

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

                   Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
                   Free form text or description fields are not recommended because they require human interpretation.
                   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.

               27. 2010EA Loop Optional Repeat 12

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

                      To supply the full name of an individual or organizational entity

                      Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued of if 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.
                      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.

                   2. 1800 · REF · Patient Event Provider Supplemental Identification · 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 (2010E) service provider (2010F). OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F). 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 identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

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

                      To specify the geographic place of the named party

                      Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

                   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. 2300 · AAA · Patient Event Provider Request Validation · Max 9 · Optional

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

                      Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

                   7. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      To specify the identifying characteristics of a provider

                      Required when the notification 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.

               28. 2010EB Loop Optional Repeat 1

                   1. 1700 · NM1 · Additional Patient Information Contact Name · Max 1 · Mandatory

                      To supply the full name of an individual or organizational entity

                      Required when additional information is sent by an information contact that is different from the information source identified in loop 2010A. If not required by this implementation guide, do not send.

                   2. 2000 · N3 · Additional Patient Information Contact Address · Max 1 · Optional

                      To specify the location of the named party

                      Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                   3. 2100 · N4 · Additional Patient Information City, State, ZIP Code · Max 1 · Optional

                      To specify the geographic place of the named party

                      Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                   4. 2200 · PER · Additional Patient Information 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.
                      By definition of the standard, if PER03 is used, PER04 is required.
                      Required when the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

               29. 2010EC 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

                   4. 2300 · AAA · Patient Event Transport Information Request Validation · Max 9 · Optional

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

                      Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

               30. 2010ED 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

               31. 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 identifying specific services associated with this patient event. If not required by this implementation guide, do not send.
                      This segment identifies the service(s) and conveys the review outcome related to that service(s).

                   2. 0200 · TRN · Service Trace Number · Max 3 · Optional

                      To uniquely identify a transaction to an application

                      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.
                      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.
                      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. 0300 · AAA · Service Request Validation · Max 9 · Optional

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

                      If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
                      Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.

                   4. 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.

                   5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                      To specify the outcome of a health care services review

                      If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.
                      Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.

                   6. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                      To specify identifying information

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

                   7. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                      To specify identifying information

                      This is the administrative number assigned by the Information receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.
                      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.

                   8. 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.
                      Use this segment for the valid date(s) during which the service can be performed.

                   9. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                      Required when Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.
                      Use this segment for the date when the certification was issued.

                   10. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                       Required when Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.

                   11. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                       Required when different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.

                   12. 0810 · SV1 · Professional Service · Max 1 · Optional

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

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

                   13. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

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

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

                   14. 0830 · SV3 · Dental Service · Max 1 · Optional

                       To specify the service line item detail for dental work

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

                   15. 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.

                   16. 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 identifying 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.

                   17. 1550 · PWK · Additional Service Information · Max 10 · Optional

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

                       Required when the information source has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) in this Service loop, and the 278 Notification, or Information Copy (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
                       Additional information requested 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 information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

                   18. 1600 · MSG · Message Text · Max 1 · Optional

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

                       Free form text or description fields are not recommended because they require human interpretation.
                       Required when needed to transmit a message to the Information Receiver 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.

                   19. 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.
                          If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.
                          Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                       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 patient event provider (2010E) service provider (2010F). OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F). 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 needed to identify a specific location for a provider that has multiple locations. 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 needed to identify a specific location for a provider that has multiple locations. 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. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

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

                          Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

                       7. 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 identifies information about the patient event and includes specific person, group practice, facility, or specialty entity providing services.
               Patient event information identified at the 2000E loop applies to all subsequent 2000F service loops. Values entered at a specific 2000F service loop override 2000E patient event information for that 2000F service loop only.

            2. 0200 · TRN · Patient Event Tracking Number · Max 3 · Optional

               To uniquely identify a transaction to an application

               Required when the information source needs to assign a unique trace number at the patient event level. 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 information receiver in the TRN segment at the corresponding level of the response.

            3. 0300 · AAA · Patient Event Request Validation · Max 9 · Optional

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

               Use this AAA segment to identify the reasons why a request could not be processed based on the data at this level of the request. If not required, may be provided at the sender's discretion.
               Required when this is a notification of a health care services review that was rejected due to invalid or missing patient event information. If not required by this implementation guide, do not send.

            4. 0400 · UM · Health Care Services Review Information · Max 1 · Mandatory

               To specify health care services review information

               Required to identify the type of health care services in this notification.

            5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

               To specify the outcome of a health care services review

               The HCR segment at the 2000E event level contains information relevant to the original decision holder for the event. Certification Action, Review Identification, Review Decision Reason Code and Second Surgical Opinion Indicator data from the original decision maker is made available in the HCR segment to the information receiver.
               Required when health care services review information applies to the event level. If not required by this implementation guide, do not send.

            6. 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 event. This is not the trace number assigned by the requester.
               Required when the certification number assigned by the UMO to the original event review outcome was used by the UMO to determine the outcome of this service review. If not required by this implementation guide, do not send.

            7. 0600 · REF · Administrative Reference Number · Max 1 · Optional

               To specify identifying information

               This is the administrative number assigned by the Information receiver in an acknowledgment from a prior notification. This is not the trace number assigned by the Information receiver.
               Required when this notification is related to an acknowledgment received from the information receiver in a prior acknowledgment transaction. If not required by this implementation guide, do not send.

            8. 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.
               The total number of DPT segments in the 2000E Loop cannot exceed 9.

            9. 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 notification is pregnancy related. If not required by this implementation guide, do not send.
               The total number of DPT segments in the 2000E Loop cannot exceed 9.

            10. 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 notification is related to the estimated date of delivery. If not required by this implementation guide, do not send.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            11. 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.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            12. 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.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            13. 0700 · DTP · Admission Date · Max 1 · Optional

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

                Required when identifying an admission review (UM01 = "AR") to identify the proposed or actual date of admission. If not required by this implementation guide, do not send.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            14. 0700 · DTP · Discharge Date · Max 1 · Optional

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

                Required when identifying 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.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            15. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                Required when certification issue date is different than the certification effective date. If not required by this implementation guide, do not send.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            16. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                Required when the certification has an expiration date that indicates the date on which the certification will expire. If not required by the implementation guide, do not send.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            17. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                Required when the certification is limited by effective dates to indicate the date or date range when the certification is effective. If not required by the implementation guide, do not send.
                The total number of DPT segments in the 2000E Loop cannot exceed 9.

            18. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                To supply information related to the delivery of health care

                Required when identifying the diagnosis code at the event level. If not required by this implementation guide, do not send.

            19. 0900 · HSD · Health Care Services Delivery · Max 1 · Optional

                To specify the delivery pattern of health care services

                Required when identifying services that have a specific pattern of delivery or usage. If not required by this implementation guide, do not send.
                Report delivery patterns for specific services in the Service Level (Loop 2000F).
                An explanation of the uses of this segment follows. HSD01 qualifies HSD02: If the value in HSD02=1 and the value in HSD01=VS (Visits), this means "one visit". Between HSD02 and HSD03 verbally insert a "per every". HSD03 qualifies HSD04: If the value in HSD04=3 and the value in HSD03=DA (Day), this means "three days". Between HSD04 and HSD05 verbally insert a "for". HSD05 qualifies HSD06: If the value in HSD06=21 and the value in HSD05=7 (Days), this means "21 days". The total message reads: 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".

            20. 1100 · CL1 · Institutional Claim Code · Max 1 · Optional

                To supply information specific to hospital claims

                Required when identifying certifications for admissions (UM01 = AR) to a facility. If not required by this implementation guide, do not send.

            21. 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.

            22. 1300 · CR2 · Spinal Manipulation Service Information · Max 1 · Optional

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

                Required when identifying 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.

            23. 1400 · CR5 · Home Oxygen Therapy Information · Max 1 · Optional

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

                Required when identifying 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.

            24. 1500 · CR6 · Home Health Care Information · Max 1 · Optional

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

                Required when identifying 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.

            25. 1550 · PWK · Additional Patient Information · Max 10 · Optional

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

                This PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12functional group rather than by paper or other medium. PWK06 is used to identify the attached electronic documentation. The number inPWK06 would be referenced in the electronic attachment.
                Required when needed to identify missing teeth for dental services, or to identify 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.
                The information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

            26. 1600 · MSG · Message Text · Max 1 · Optional

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

                Required when it is necessary to send additional information about the patient event that could not otherwise be codified within the 2000E Loop. If not required by this implementation guide, do not send.
                Free form text or description fields are not recommended because they require human interpretation.
                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.

            27. 2010EA Loop Optional Repeat 12

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

                   To supply the full name of an individual or organizational entity

                   Required when loop 2000E UM01 = AR (Admission Review) or when loop 2000F is not valued of if 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.
                   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.

                2. 1800 · REF · Patient Event Provider Supplemental Identification · 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 (2010E) service provider (2010F). OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F). 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 identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

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

                   To specify the geographic place of the named party

                   Required when identifying a specific location for a patient event provider that has multiple locations. If not required, may be provided at the sender's discretion.

                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. 2300 · AAA · Patient Event Provider Request Validation · Max 9 · Optional

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

                   Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

                7. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                   To specify the identifying characteristics of a provider

                   Required when the notification 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.

            28. 2010EB Loop Optional Repeat 1

                1. 1700 · NM1 · Additional Patient Information Contact Name · Max 1 · Mandatory

                   To supply the full name of an individual or organizational entity

                   Required when additional information is sent by an information contact that is different from the information source identified in loop 2010A. If not required by this implementation guide, do not send.

                2. 2000 · N3 · Additional Patient Information Contact Address · Max 1 · Optional

                   To specify the location of the named party

                   Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                3. 2100 · N4 · Additional Patient Information City, State, ZIP Code · Max 1 · Optional

                   To specify the geographic place of the named party

                   Required when the request for additional patient information must be routed to a specific office location. If not required by this implementation guide, do not send.

                4. 2200 · PER · Additional Patient Information 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.
                   By definition of the standard, if PER03 is used, PER04 is required.
                   Required when the request for additional patient information must be routed to a specific contact, electronic mail, facsimile, or phone number. If not required by this implementation guide, do not send.

            29. 2010EC 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

                4. 2300 · AAA · Patient Event Transport Information Request Validation · Max 9 · Optional

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

                   Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

            30. 2010ED 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

            31. 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 identifying specific services associated with this patient event. If not required by this implementation guide, do not send.
                   This segment identifies the service(s) and conveys the review outcome related to that service(s).

                2. 0200 · TRN · Service Trace Number · Max 3 · Optional

                   To uniquely identify a transaction to an application

                   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.
                   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.
                   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. 0300 · AAA · Service Request Validation · Max 9 · Optional

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

                   If the non-certification is related to a medical necessity/benefits decision, use the HCR segment.
                   Required when this is a notification of a health care services review that was rejected due to invalid or missing service information. If not required by this implementation guide, do not send.

                4. 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.

                5. 0500 · HCR · Health Care Services Review · Max 1 · Optional

                   To specify the outcome of a health care services review

                   If the HCR segment is sent in this 2000F Service level loop, it will override an HCR segment sent in the Patient Event loop (2000E) for this service only.
                   Required when the HCR segment is not used in 2000E, or if HCR01 in 2000E is A2. If not required by this implementation guide, do not send.

                6. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                   To specify identifying information

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

                7. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                   To specify identifying information

                   This is the administrative number assigned by the Information receiver for the original acknowledgment of the notification associated with this service review. This is not the trace number assigned by the requester.
                   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.

                8. 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.
                   Use this segment for the valid date(s) during which the service can be performed.

                9. 0700 · DTP · Certification Issue Date · Max 1 · Optional

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

                   Required when Certification Issue Date is different from the Patient Event Certification Issue Date in Loop 2000E. If not required by this implementation guide, do not send.
                   Use this segment for the date when the certification was issued.

                10. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                    Required when Certification Expiration Date is different from the Patient Event Certification Expiration Date in Loop 2000E. If not required by this implementation guide, do not send.

                11. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                    Required when different from the Certification Effective Date in Loop 2000E. If not required by this implementation guide, do not send.

                12. 0810 · SV1 · Professional Service · Max 1 · Optional

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

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

                13. 0820 · SV2 · Institutional Service Line · Max 1 · Optional

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

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

                14. 0830 · SV3 · Dental Service · Max 1 · Optional

                    To specify the service line item detail for dental work

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

                15. 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.

                16. 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 identifying 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.

                17. 1550 · PWK · Additional Service Information · Max 10 · Optional

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

                    Required when the information source has additional documentation (electronic, paper, or other medium) associated with this health care services review that applies to the service(s) in this Service loop, and the 278 Notification, or Information Copy (ST-SE) does not support this information in its segments and data elements. If not required by this implementation guide, do not send.
                    Additional information requested 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 information source can also use this PWK segment to identify paperwork that is held at the provider's office and is available upon request by the information receiver. Use code AA in PWK02 to convey this specific use of the PWK segment. See code note under PWK02, code AA.

                18. 1600 · MSG · Message Text · Max 1 · Optional

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

                    Free form text or description fields are not recommended because they require human interpretation.
                    Required when needed to transmit a message to the Information Receiver 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.

                19. 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.
                       If Loop 2010EA is not valued, Loop 2010F must be valued for each service associated with this patient event.
                       Required when identifying a service provider, specialist, or specialty entity for this service and is different from the provider, specialist, or specialty entity identified in Loop 2010EA (Patient Event Provider Name). If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

                    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 patient event provider (2010E) service provider (2010F). OR Required prior to the mandated NPI implementation date when necessary for the UMO to identify the patient event provider (2010E) service provider (2010F). 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 needed to identify a specific location for a provider that has multiple locations. 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 needed to identify a specific location for a provider that has multiple locations. 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. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

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

                       Required when this is a notification of a health care services review that was rejected due to invalid or missing service provider information. If not required by this implementation guide, do not send.

                    7. 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)