278

Health Care Services Review - Request for Review

Functional Group=HI

This Draft Standard for Trial Use 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.

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

ISA

Interchange Control Header

M

1

 

 

Required

   

 

 

GS

Functional Group Header

M

1

 

 

Required

   

Heading:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

010

ST

Transaction Set Header

M

1

 

 

Required

   

 

020

BHT

Beginning of Hierarchical Transaction

M

1

 

 

Required

   

Detail:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

LOOP ID - 2000A

 

 

1

 

 

 

 

 

010

HL

Utilization Management Organization (UMO) Level

M

1

 

 

Required

   

LOOP ID - 2010A

 

 

1

 

 

 

 

 

170

NM1

Utilization Management Organization (UMO) Name

O

1

 

 

Required

   

LOOP ID - 2000B

 

 

1

 

 

 

 

 

010

HL

Requester Level

M

1

 

 

Required

   

LOOP ID - 2010B

 

 

1

 

 

 

 

 

170

NM1

Requester Name

O

1

 

 

Required

   

 

180

REF

Requester Supplemental Identification

O

8

 

 

Situational

   

 

200

N3

Requester Address

O

1

 

 

Situational

   

 

210

N4

Requester City/State/ZIP Code

O

1

 

 

Situational

   

 

220

PER

Requester Contact Information

O

1

 

 

Situational

   

 

240

PRV

Requester Provider Information

O

1

 

 

Situational

   

LOOP ID - 2000C

 

 

1

 

 

 

 

 

010

HL

Subscriber Level

M

1

 

 

Required

   

 

020

TRN

Patient Event Tracking Number

O

2

 

 

Situational

   

 

070

DTP

Accident Date

O

1

 

 

Situational

   

 

070

DTP

Last Menstrual Period Date

O

1

 

 

Situational

   

 

070

DTP

Estimated Date of Birth

O

1

 

 

Situational

   

 

070

DTP

Onset of Current Symptoms or Illness Date

O

1

 

 

Situational

   

 

080

HI

Subscriber Diagnosis

O

1

 

 

Situational

   

 

155

PWK

Additional Patient Information

O

10

 

 

Situational

   

LOOP ID - 2010CA

 

 

1

 

 

 

 

 

170

NM1

Subscriber Name

O

1

 

 

Required

   

 

180

REF

Subscriber Supplemental Identification

O

9

 

 

Situational

   

 

250

DMG

Subscriber Demographic Information

O

1

 

 

Situational

   

LOOP ID - 2000D

 

 

1

 

 

 

 

 

010

HL

Dependent Level

O

1

 

 

Situational

   

 

020

TRN

Patient Event Tracking Number

O

2

 

 

Situational

   

 

070

DTP

Accident Date

O

1

 

 

Situational

   

 

070

DTP

Last Menstrual Period Date

O

1

 

 

Situational

   

 

070

DTP

Estimated Date of Birth

O

1

 

 

Situational

   

 

070

DTP

Onset of Current Symptoms or Illness Date

O

1

 

 

Situational

   

 

080

HI

Dependent Diagnosis

O

1

 

 

Situational

   

 

155

PWK

Additional Patient Information

O

10

 

 

Situational

   

LOOP ID - 2010DA

 

 

1

 

 

 

 

 

170

NM1

Dependent Name

O

1

 

 

Required

   

 

180

REF

Dependent Supplemental Identification

O

3

 

 

Situational

   

 

250

DMG

Dependent Demographic Information

O

1

 

 

Situational

   

 

260

INS

Dependent Relationship

O

1

 

 

Situational

   

LOOP ID - 2000E

 

 

>1

 

 

 

 

 

010

HL

Service Provider Level

M

1

 

 

Required

   

 

160

MSG

Message Text

O

1

 

 

Not recommended

   

LOOP ID - 2010E

 

 

3

 

 

 

 

 

170

NM1

Service Provider Name

O

1

 

 

Required

   

 

180

REF

Service Provider Supplemental Identification

O

7

 

 

Situational

   

 

200

N3

Service Provider Address

O

1

 

 

Situational

   

 

210

N4

Service Provider City/State/ZIP Code

O

1

 

 

Situational

   

 

220

PER

Service Provider Contact Information

O

1

 

 

Situational

   

 

240

PRV

Service Provider Information

O

1

 

 

Situational

   

LOOP ID - 2000F

 

 

>1

 

 

 

 

 

010

HL

Service Level

M

1

 

 

Required

   

 

020

TRN

Service Trace Number

O

2

 

 

Situational

   

 

040

UM

Health Care Services Review Information

O

1

 

 

Required

   

 

060

REF

Previous Certification Identification

O

1

 

 

Situational

   

 

070

DTP

Service Date

O

1

 

 

Situational

   

 

070

DTP

Admission Date

O

1

 

 

Situational

   

 

070

DTP

Discharge Date

O

1

 

 

Situational

   

 

070

DTP

Surgery Date

O

1

 

 

Situational

   

 

080

HI

Procedures

O

1

 

 

Situational

   

 

090

HSD

Health Care Services Delivery

O

1

 

 

Situational

   

 

100

CRC

Patient Condition Information

O

6

 

 

Situational

   

 

110

CL1

Institutional Claim Code

O

1

 

 

Situational

   

 

120

CR1

Ambulance Transport Information

O

1

 

 

Situational

   

 

130

CR2

Spinal Manipulation Service Information

O

1

 

 

Situational

   

 

140

CR5

Home Oxygen Therapy Information

O

1

 

 

Situational

   

 

150

CR6

Home Health Care Information

O

1

 

 

Situational

   

 

155

PWK

Additional Service Information

O

10

 

 

Situational

   

 

160

MSG

Message Text

O

1

 

 

Not recommended

   

 

280

SE

Transaction Set Trailer

M

1

 

 

Required

   

Not Defined:

 

Pos

Id

Segment Name

Req

Max Use

Repeat

Notes

Usage

 

 

 

 

GE

Functional Group Trailer

M

1

 

 

Required

   

 

 

IEA

Interchange Control Trailer

M

1

 

 

Required

   


It is recommended that separate transaction sets be used for different patients.


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