UM Health Care Services Review Information

To specify health care services review information

Position
Element
Name
Type
Requirement
Min
Max
Repeat
UM01
Request Category Code
Identifier (ID)
Mandatory
1
2
1
Code indicating a type of request
UM02
Certification Type Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of certification
UM03
Service Type Code
Identifier (ID)
Optional
1
2
1
Code identifying the classification of service
UM04
Health Care Service Location Information
Composite (composite)
Optional
1
01
Facility Code Value
String (AN)
Mandatory
1
2
-
Code identifying the type of facility where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format
02
Facility Code Qualifier
Identifier (ID)
Optional
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01 and C023-03.
03
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
UM05
Related Causes Information
Composite (composite)
Optional
1
01
Related-Causes Code
Identifier (ID)
Mandatory
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
02
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
03
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
04
State or Province Code
Identifier (ID)
Optional
2
2
-
Code (Standard State/Province) as defined by appropriate government agency
C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
05
Country Code
Identifier (ID)
Optional
2
3
-
Code identifying the country
UM06
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
UM07
Current Health Condition Code
Identifier (ID)
Optional
1
1
1
Code indicating current health condition of the individual
UM08
Prognosis Code
Identifier (ID)
Optional
1
1
1
Code indicating physician's prognosis for the patient
UM09
Release of Information Code
Identifier (ID)
Optional
1
1
1
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
UM10
Delay Reason Code
Identifier (ID)
Optional
1
2
1
Code indicating the reason why a request was delayed

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