UM Health Care Services Review Information

To specify health care services review information

Sequence

Element

Name

Type

Requirement

Min

Max

Repeat

01

1525

Request Category Code

Identifier (ID)

Mandatory

1

2

1

Code indicating a type of request

Codes (7)

02

1322

Certification Type Code

Identifier (ID)

Optional

1

1

1

Code indicating the type of certification

Codes (17)

03

1271

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).

04

C023

Health Care Service Location Information

Composite (composite)

Optional

1

01

1331

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

1332

Facility Code Qualifier

Identifier (ID)

Mandatory

1

2

-

Code identifying the type of facility referenced

C023-02 qualifies C023-01.

Codes (2)

03

1325

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

05

C024

Related Causes Information

Composite (composite)

Optional

1

01

1362

Related-Causes Code

Identifier (ID)

Mandatory

2

3

-

Code identifying an accompanying cause of an illness, injury or an accident

Codes (6)

02

1362

Related-Causes Code

Identifier (ID)

Optional

2

3

-

Code identifying an accompanying cause of an illness, injury or an accident

Codes (6)

03

1362

Related-Causes Code

Identifier (ID)

Optional

2

3

-

Code identifying an accompanying cause of an illness, injury or an accident

Codes (6)

04

156

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

26

Country Code

Identifier (ID)

Optional

2

3

-

Code identifying the country

06

1338

Level of Service Code

Identifier (ID)

Optional

1

3

1

Code specifying the level of service rendered

Codes (19)

07

1213

Current Health Condition Code

Identifier (ID)

Optional

1

1

1

Code indicating current health condition of the individual

Codes (13)

08

923

Prognosis Code

Identifier (ID)

Optional

1

1

1

Code indicating physician's prognosis for the patient

Codes (8)

09

1363

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

Codes (6)

10

1514

Delay Reason Code

Identifier (ID)

Optional

1

2

1

Code indicating the reason why a request was delayed

Codes (14)