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

Position
Segment
Name
Max use
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
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

Position
Segment
Name
Max use
HL Loop
Repeat >1
0100
Hierarchical LevelMandatory
Max 1
To identify dependencies among and the content of hierarchically related groups of data segments
0200
TraceOptional
Max 9
To uniquely identify a transaction to an application
0300
Request ValidationOptional
Max 9
To specify the validity of the request and indicate follow-up action authorized
0400
Health Care Services Review InformationOptional
Max 1
To specify health care services review information
0500
Health Care Services ReviewOptional
Max 1
To specify the outcome of a health care services review
0600
Reference IdentificationOptional
Max 9
To specify identifying information
0700
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
0800
Health Care Information CodesOptional
Max 1
To supply information related to the delivery of health care
0900
Health Care Services DeliveryOptional
Max 1
To specify the delivery pattern of health care services
1000
Conditions IndicatorOptional
Max 9
To supply information on conditions
1100
Claim CodesOptional
Max 1
To supply information specific to hospital claims
1200
Ambulance CertificationOptional
Max 1
To supply information related to the ambulance service rendered to a patient
1300
Chiropractic CertificationOptional
Max 1
To supply information related to the chiropractic service rendered to a patient
1350
Enteral or Parenteral Therapy CertificationOptional
Max 1
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
1400
Oxygen Therapy CertificationOptional
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
1500
Home Health Care CertificationOptional
Max 1
To supply information related to the certification of a home health care patient
1520
Home Health Treatment Plan CertificationOptional
Max 1
To supply information related to the home health care plan of treatment and services
1530
Pacemaker CertificationOptional
Max 1
To supply information related to Pacemaker registry
1550
PaperworkOptional
Max >1
To identify the type or transmission or both of paperwork or supporting information
1600
Message TextOptional
Max 1
To provide a free-form format that allows the transmission of text information
NM1 Loop
Repeat >1
1700
Individual or Organizational NameMandatory
Max 1
To supply the full name of an individual or organizational entity
1800
Reference IdentificationOptional
Max 9
To specify identifying information
2000
Address InformationOptional
Max 1
To specify the location of the named party
2100
Geographic LocationOptional
Max 1
To specify the geographic place of the named party
2200
Administrative Communications ContactOptional
Max 3
To identify a person or office to whom administrative communications should be directed
2300
Request ValidationOptional
Max 9
To specify the validity of the request and indicate follow-up action authorized
2400
Provider InformationOptional
Max 1
To specify the identifying characteristics of a provider
2500
Demographic InformationOptional
Max 1
To supply demographic information
2600
Insured BenefitOptional
Max 1
To provide benefit information on insured entities
2700
Date or Time or PeriodOptional
Max 9
To specify any or all of a date, a time, or a time period
2800
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)

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