278 Health Care Services Review Information

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

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. 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
  1. HL Loop Mandatory
    Repeat >1
    1. To identify dependencies among and the content of hierarchically related groups of data segments

    2. To uniquely identify a transaction to an application

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

    4. To specify health care services review information

    5. To specify the outcome of a health care services review

    6. To specify identifying information

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

    8. To supply information related to the delivery of health care

    9. To specify the delivery pattern of health care services

    10. To supply information on conditions

    11. To supply information specific to hospital claims

    12. To supply information related to the ambulance service rendered to a patient

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

    14. To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

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

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

    17. To supply information related to the home health care plan of treatment and services

    18. To supply information related to Pacemaker registry

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

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

    21. NM1 Loop Optional
      Repeat >1
      1. To supply the full name of an individual or organizational entity

      2. To specify identifying information

      3. To specify additional names

      4. To specify the location of the named party

      5. To specify the geographic place of the named party

      6. To identify a person or office to whom administrative communications should be directed

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

      8. To specify the identifying characteristics of a provider

      9. To supply demographic information

      10. To provide benefit information on insured entities

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

  2. 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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