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
Industry Code
String (AN)
Optional
1
30
1
Code indicating a code from a specific industry code list
UM03 is the Service Type (Code Source 958).
UM04
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)
Mandatory
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01.
03
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee
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 specifying the 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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