UM Health Care Services Review Information

To specify health care services review information

Position
Element
Name
Type
Requirement
Min
Max
Repeat
UM-01
Request Category Code
Identifier (ID)
Mandatory
1
2
1
Code indicating a type of request
UM-02
Certification Type Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of certification
UM-03
Service Type Code
Identifier (ID)
Optional
1
2
1
Code identifying the classification of service
UM-04
Health Care Service Location Information
Composite (composite)
Optional
1
01
Facility Code Value
String (AN)
Mandatory
1
3
-
Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
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
UM-05
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
UM-06
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
UM-07
Current Health Condition Code
Identifier (ID)
Optional
1
1
1
Code indicating current health condition of the individual
UM-08
Prognosis Code
Identifier (ID)
Optional
1
1
1
Code indicating physician's prognosis for the patient
UM-09
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
UM-10
Delay Reason Code
Identifier (ID)
Optional
1
2
1
Code indicating the reason why a request was delayed

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