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278 Health Care Services Review Information

Functional Group HI

X12N Insurance Subcommittee

This Draft Standard for Trial Use 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

Sequence
Segment
Name
Max use
010
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
020
Beginning of Hierarchical TransactionMandatory
Max 1
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

Sequence
Segment
Name
Max use
HL Loop
Repeat >1
010
Hierarchical LevelMandatory
Max 1
To identify dependencies among and the content of hierarchically related groups of data segments
020
Trace
Max 9
To uniquely identify a transaction to an application
030
Request Validation
Max 9
To specify the validity of the request and indicate follow-up action authorized
040
Health Care Services Review Information
Max 1
To specify health care services review information
050
Health Care Services Review
Max 1
To specify the outcome of a health care services review
060
Reference Identification
Max 9
To specify identifying information
070
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
080
Health Care Information Codes
Max 1
To supply information related to the delivery of health care
090
Health Care Services Delivery
Max 1
To specify the delivery pattern of health care services
100
Conditions Indicator
Max 9
To supply information on conditions
110
Claim Codes
Max 1
To supply information specific to hospital claims
120
Ambulance Certification
Max 1
To supply information related to the ambulance service rendered to a patient
130
Chiropractic Certification
Max 1
To supply information related to the chiropractic service rendered to a patient
140
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
150
Home Health Care Certification
Max 1
To supply information related to the certification of a home health care patient
155
Paperwork
Max >1
To identify the type or transmission or both of paperwork or supporting information
160
Message Text
Max 1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
170
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
180
Reference Identification
Max 9
To specify identifying information
190
Additional Name Information
Max 1
To specify additional names or those longer than 35 characters in length
200
Address Information
Max 1
To specify the location of the named party
210
Geographic Location
Max 1
To specify the geographic place of the named party
220
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
230
Request Validation
Max 9
To specify the validity of the request and indicate follow-up action authorized
240
Provider Information
Max 1
To specify the identifying characteristics of a provider
250
Demographic Information
Max 1
To supply demographic information
260
Insured Benefit
Max 1
To provide benefit information on insured entities
270
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
280
Transaction Set TrailerMandatory
Max 1
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.

Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.