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EDI 278 X216 - Health Care Services Review Information - Acknowledgment

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

   This segment indicates the start of a health care services review notification acknowledgment response transaction set with all the supporting information. This transaction set is the electronic equivalent of a phone, fax, or paper-based receipt acknowledgment.

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 indicates the information source hierarchical level. The information source corresponds to the source of the notification or information copy.

   2. 0300 · AAA · Notification Validation · Max 9 · Optional

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

      Required when the notification cannot be processed at a system or application level based on the trading partner information contained in the Functional Group Header (GS). If not required by this implementation guide, do not send.

   3. 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

         This NM1 loop 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. If the sender is not the same entity as the information source, use the first NM1 loop to identify the information sender and the second NM1 loop to identify the information source.
         The second NM1 loop is required when the sender is not the same entity as the information source. If not required by this implementation guide, do not send.

      2. 1800 · REF · Information Source Supplemental Identification · Max 9 · Optional

         To specify identifying information

         Required when valued on the notification and used by the receiver to identify the information source or sender. If not required by this implementation guide, do not send.

      3. 2300 · AAA · Information Source Validation · Max 9 · Optional

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

         Use this segment to convey rejection information regarding the entity;that initiated a notification or information copy transaction.
         Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

      4. 2400 · PRV · Information Source Provider Information · Max 1 · Optional

         To specify the identifying characteristics of a provider

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

   4. 2000B Loop Optional 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 information receiver. The information receiver is the entity that received the notification.
         Required when this loop is used. If the information receiver's system processed any of the information contained in Loop 2000B of the notification, the acknowledgment must return Loop 2000B. If the information receiver's system was unable to process any data beyond Loop 2000A of the notification, then Loop 2000B is not used. If not required by this implementation guide, do not send.

      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 NM1 loop identifies the notification receiver.

         2. 2200 · PER · Information Receiver 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 phone 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 source 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.

         3. 2300 · AAA · Information Receiver Notification Validation · Max 9 · Optional

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

            Use this AAA segment to report the reasons why the information receiver cannot receive the notification at a system or application level based on the information source identified in Loop 2010A.
            Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

      3. 2000C Loop Optional 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. The subscriber could also be the patient. If the subscriber is the patient, then the dependent hierarchical level (Loop 2000D) is not used.
            Required when the information receiver has detected no errors at the parent level (Loop 2000B) of the notification. If not required by this implementation guide, do not send.

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

            To uniquely identify a transaction to an application

            Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
            If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
            If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.
            Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.

         3. 0300 · AAA · Subscriber Notification 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 the notification could not be received based on the contents of the HI Subscriber Diagnosis segment or the DTP date segments in Loop 2000C of the notification.
            Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

         4. 0600 · REF · Notification Receipt Number · Max 1 · Optional

            To specify identifying information

            Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.

         5. 2010C Loop Mandatory Repeat 1

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

               To supply the full name of an individual or organizational entity

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

               To specify identifying information

               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.
               Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send.

            3. 2300 · AAA · Subscriber Notification Validation · Max 9 · Optional

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

               Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

            4. 2500 · DMG · Subscriber Demographic Information · Max 1 · Optional

               To supply demographic information

               Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send.

            5. 2600 · INS · Subscriber Relationship · Max 1 · Optional

               To provide benefit information on insured entities

               Required when the subscriber's role in the military is used by the information receiver to identify the subscriber. If not required by this implementation guide, do not send.

         6. 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

               Required segments in this loop are required only when this loop is used.
               Required when valued on the notification and the information receiver has detected no errors at the parent level (Loop 2000C) of the notification. If not required by this implementation guide, do not send.

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

               To uniquely identify a transaction to an application

               Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 acknowledgment response if one is returned.
               If the 278 notification transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 notification in the 278 acknowledgment response transaction.
               Required when this loop is returned and the notification contained a tracking number at this level on the notification, or if the receiver or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
               If the 278 notification passes through a clearinghouse that adds their own TRN in addition to an information source TRN, the clearinghouse will receive an acknowledgment from the information receiver containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information receiver has assigned a TRN, the information receiver's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the information source, the clearinghouse must change the value in their TRN01 to "1" because, from the information source's perspective, this is not a referenced transaction trace number.

            3. 0300 · AAA · Dependent Notification 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 the notification could not be processed based on the contents of the HI Dependent Diagnosis Segment or the DTP date segments in Loop 2000D of the notification.
               Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

            4. 0600 · REF · Notification Receipt Number · Max 1 · Optional

               To specify identifying information

               Required when the information receiver returns a receipt number to indicate receipt of the notification. If not required by this implementation guide, do not send.

            5. 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.
                  NM108 and NM109 are situational on the acknowledgment but Not Used on the notification. This enables the information receiver (UMO for example) to return a unique member ID for the dependent that was not known to the information source at the time of the review. Normally, if the dependent has a unique member ID, Loop 2000D is not used.

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

                  To specify identifying information

                  Required when valued on the notification and used by the information receiver to identify the Subscriber or when REF01 = "EJ" (Patient Account Number) is valued on the notification. If not required by this implementation guide, do not send.

               3. 2300 · AAA · Dependent Notification Validation · Max 9 · Optional

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

                  Required when the notification is not valid at this level. If not required by this implementation guide, do not send.

               4. 2500 · DMG · Dependent Demographic Information · Max 1 · Optional

                  To supply demographic information

                  Required when valued on the notification and birth date (DMG02) or gender (DMG03) was used by the information receiver to identify the patient. If not required by this implementation guide, do not send.

               5. 2600 · INS · Dependent Relationship · Max 1 · Optional

                  To provide benefit information on insured entities

                  Required when valued on the notification and used by the information receiver to identify the patient. If not required by this implementation guide, do not send.

            6. 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

                  Required when the information receiver has detected errors at the patient event or subsequent service levels of the notification or when a receipt number is assigned at the event level of a received notification. If not required by this implementation guide, do not send.
                  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 this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
                  Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.
                  If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
                  If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.

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

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

                  Required when the notification is not valid at this level. 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 review notification to which this acknowledgment pertains.

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

                  To specify the outcome of a health care services review

                  Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.
                  If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.
                  If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

               6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

                  To specify identifying information

                  Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.
                  This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver.

               7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

                  To specify identifying information

                  Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.

               8. 0700 · DTP · Event Date · Max 1 · Optional

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

                  Use this segment for the valid date(s) during which this event can occur. If not required, do not send.
                  Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

               9. 0700 · DTP · Admission Date · Max 1 · Optional

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

                  Use this segment for the proposed or actual date of admission.
                  Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

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

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

                   Use this segment for the proposed or actual date of discharge from a facility.
                   Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

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

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

                   Use this segment for the date when the certification was issued.
                   Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

               12. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                   Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

               13. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                   Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

               14. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                   To supply information related to the delivery of health care

                   Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
                   This segment is used to hold the event level diagnosis code information that was part of the notification transaction.

               15. 2010E 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 valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
                      Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error.

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

                      To specify identifying information

                      Use the NM1 segment for the primary identifier.
                      Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

                   3. 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 the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.

                   4. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                      To specify the identifying characteristics of a provider

                      Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

               16. 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 the information receiver has detected errors at this level of the notification, or assigns a receipt number to each service level on the notification that it receives. If not required by this implementation guide, do not send.

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

                      To uniquely identify a transaction to an application

                      Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
                      Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.
                      If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
                      If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.

                   3. 0300 · AAA · Service Request Validation · Max 9 · Optional

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

                      Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. 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 necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. 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

                      Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.
                      If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification.

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

                      To specify identifying information

                      Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.

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

                      To specify identifying information

                      Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.
                      This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.
                      This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver.

                   8. 0700 · DTP · Service Date · Max 1 · Optional

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

                      Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.
                      Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

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

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

                      Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.
                      Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

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

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

                       Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.
                       Required when valued on the notification and the notification is not valid at this segment. 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

                       Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.
                       Required when valued on the notification and the notification is not valid at this segment. 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

                       Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.
                       Required when valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

                   16. 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

                          Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
                          Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level.

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

                          To specify identifying information

                          Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

                       3. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

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

                          Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send.

                       4. 2400 · PRV · Service Provider Information · Max 1 · Optional

                          To specify the identifying characteristics of a provider

                          Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

         7. 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

               Required when the information receiver has detected errors at the patient event or subsequent service levels of the notification or when a receipt number is assigned at the event level of a received notification. If not required by this implementation guide, do not send.
               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 this loop is returned and the notification contained a tracking number at this level on the notification, or if the information source or clearinghouse assigns a trace number to this patient event in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
               Any trace numbers provided at this level on the notification must be returned by the information sender at this level of the 278 notification.
               If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
               If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.

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

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

               Required when the notification is not valid at this level. 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 review notification to which this acknowledgment pertains.

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

               To specify the outcome of a health care services review

               Required when this segment is valued on the notification at the event level. If not required by this implementation guide, do not send.
               If this segment is used, the values in the segment must echo the values contained in the same segment of the notification.
               If the acknowledgment contains Service level information (Loop 2000F) where the HCR segment is valued, the HCR values at the Service level override the HCR values at the Patient Event level for that service only.

            6. 0600 · REF · Administrative Reference Number · Max 1 · Optional

               To specify identifying information

               Required when the information source of the acknowledgment transaction assigns an administrative reference number at the event loop level. If not required by this implementation guide, do not send.
               This is the administrative number assigned by the Information Sender in an acknowledgment to the original notification at the event level. This is not the trace number assigned by the Information Receiver.

            7. 0600 · REF · Previous Review Authorization Number · Max 1 · Optional

               To specify identifying information

               Required when valued on the notification at the Event Level or if the acknowledgment information sender has determined that the event level notification is a duplicate of a previously received event notification that has an assigned certification number. If not required by this implementation guide, do not send.

            8. 0700 · DTP · Event Date · Max 1 · Optional

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

               Use this segment for the valid date(s) during which this event can occur. If not required, do not send.
               Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

            9. 0700 · DTP · Admission Date · Max 1 · Optional

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

               Use this segment for the proposed or actual date of admission.
               Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

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

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

                Use this segment for the proposed or actual date of discharge from a facility.
                Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

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

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

                Use this segment for the date when the certification was issued.
                Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

            12. 0700 · DTP · Certification Expiration Date · Max 1 · Optional

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

                Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

            13. 0700 · DTP · Certification Effective Date · Max 1 · Optional

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

                Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.

            14. 0800 · HI · Patient Diagnosis · Max 1 · Optional

                To supply information related to the delivery of health care

                Required when valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
                This segment is used to hold the event level diagnosis code information that was part of the notification transaction.

            15. 2010E 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 valued on the notification and the notification is not valid at this level. If not required by this implementation guide, do not send.
                   Use this segment to return the name and/or identification number of the service provider (person, group, or facility) specialist, or specialty entity that was in error.

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

                   To specify identifying information

                   Use the NM1 segment for the primary identifier.
                   Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

                3. 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 the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. If not required by this implementation guide, do not send.

                4. 2400 · PRV · Patient Event Provider Information · Max 1 · Optional

                   To specify the identifying characteristics of a provider

                   Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

            16. 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 the information receiver has detected errors at this level of the notification, or assigns a receipt number to each service level on the notification that it receives. If not required by this implementation guide, do not send.

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

                   To uniquely identify a transaction to an application

                   Required when this service level is returned and any trace numbers were provided at this level on the notification, or if the information receiver or clearinghouse assigns a trace number to this service in the acknowledgment for tracking purposes. If not required by this implementation guide, do not send.
                   Any trace numbers provided at this level on the notification must be returned by the information receiver at this level of the 278 notification.
                   If the 278 notification transaction passed through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options: If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 acknowledgment to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment. If the second or subsequent clearinghouse does not need to assign their own TRN segment, they should merely pass all TRN segments received in the 278 acknowledgment transaction.
                   If the 278 notification passed through a clearinghouse that adds their own TRN in addition to the information source's TRN, the clearinghouse will receive an acknowledgment from the information source containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the information source has assigned a TRN, the information source's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the acknowledgment's information receiver, the clearinghouse must change the value in their TRN01 to "1" because, from the information receiver's perspective, this is not a referenced transaction trace number.

                3. 0300 · AAA · Service Request Validation · Max 9 · Optional

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

                   Required when the notification is not valid at this level to indicate the data condition that prohibits processing of the notification, or information copy. 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 necessary to identify the type of health care services review notification if different from the Patient Event level and the Service Level is returned in the acknowledgment. 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

                   Required if this segment is valued on the notification and the notification contains a value in HCR02 and the service level is returned in the acknowledgment. If not required by this implementation guide, do not send.
                   If this segment is used, the values in HCR01 and HCR02 must echo the values contained in the same data elements of the notification.

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

                   To specify identifying information

                   Required when valued on the notification at the Service Level or if the information receiver has determined that this service level notification is a duplicate (AAA03 = 91) of a previously received service review notification that has an assigned certification number. If not required by this implementation guide, do not send.

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

                   To specify identifying information

                   Required when the information receiver assigns a separate administrative reference number to acknowledge receipt of each service loop contained in a notification. If not required by this implementation guide, do not send.
                   This number can be used by the information Source on notifications when UM02 = 3, 4, R, S. to reference previous Acknowledgments.
                   This is the administrative number assigned by the Information Receiver in acknowledgment to the original notification associated with this service level. This is not the trace number assigned by the Information Receiver.

                8. 0700 · DTP · Service Date · Max 1 · Optional

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

                   Use this segment to indicate the service dates that prohibits the information receiver from accepting this notification.
                   Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

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

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

                   Use this segment to indicate the certification issue dates that prohibits the information receiver from accepting this notification.
                   Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

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

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

                    Use this segment to indicate the certification expiration dates that prohibits the information receiver from accepting this notification.
                    Required when valued on the notification and the notification is not valid at this segment. 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

                    Use this segment to indicate the certification effective dates that prohibits the information receiver from accepting this notification.
                    Required when valued on the notification and the notification is not valid at this segment. 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

                    Use this segment to indicate the professional service data that prohibits the information receiver from accepting this notification.
                    Required when valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. 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 valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.

                16. 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

                       Required when valued on the notification and the notification is not valid at this segment. If not required by this implementation guide, do not send.
                       Use this segment to return the name and identification number of the service provider (person, group, or facility) or the specialty entity that was not valid at this level.

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

                       To specify identifying information

                       Required when used by the Information Receiver to identify the Patient Event Provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

                    3. 2300 · AAA · Service Provider Request Validation · Max 9 · Optional

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

                       Required when the request is not valid at this level to indicate the data condition that prohibits processing of the Notification, or Information Copy. If not required by this implementation guide, do not send.

                    4. 2400 · PRV · Service Provider Information · Max 1 · Optional

                       To specify the identifying characteristics of a provider

                       Required when used by the Information Receiver to identify the provider and the notification is not valid at this level. If not required by this implementation guide, do not send.

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)