Health Care Services Review Information

Pos: 040

Max: 1

Detail - Optional

Loop: 2000F

Elements: 10

User Option (Usage): Required

To specify health care services review information

Element Summary:

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	UM01	1525	Request Category Code Description: Code indicating a type of request	M	ID	1/2	Required

Code

Name

Admission Review

Use this code to request admission to a facility.

Health Services Review

Use this code for a request for review of services related to an episode of care.

Specialty Care Review

Use this code for a request for a referral to a specialty provider.

UM02

1322

Certification Type Code
Description: Code indicating the type of certification

1/1

Required

Code

Name

Appeal - Immediate

Use this value only for appeals of review decisions where the level of service required is emergency or urgent. If UM02 = 1 then UM06 must be valued.

Appeal - Standard

Use this value for appeals of review decisions where the level of service is not emergency or urgent.

Cancel

Extension

Initial

Renewal

Revised

UM03

1365

Service Type Code
Description: Code identifying the classification of service
Required if known by the requester. Use the HI Procedures Segment to indicate specific service and procedure codes. Some of the values for UM03 include a facility type qualifier, for example A7 (Psychiatric - Inpatient) and A8 (Psychiatric - Outpatient). If the facility type is known by the requester and the UM03 service type contains an appropriate facility type qualifier, use the UM03 value to specify both the type of service and the facility type.

1/2

Situational

	Code	Name
	1	Medical Care
	2	Surgical
	3	Consultation
	4	Diagnostic X-Ray
	5	Diagnostic Lab
	6	Radiation Therapy
	7	Anesthesia
	8	Surgical Assistance
	12	Durable Medical Equipment Purchase
	14	Renal Supplies in the Home
	15	Alternate Method Dialysis
	16	Chronic Renal Disease (CRD) Equipment
	17	Pre-Admission Testing
	18	Durable Medical Equipment Rental
	20	Second Surgical Opinion
	21	Third Surgical Opinion
	23	Diagnostic Dental
	24	Periodontics
	25	Restorative
	26	Endodontics
	27	Maxillofacial Prosthetics
	28	Adjunctive Dental Services
	33	Chiropractic
	34	Chiropractic Office Visits
	35	Dental Care
	36	Dental Crowns
	37	Dental Accident
	38	Orthodontics
	39	Prosthodontics
	40	Oral Surgery
	42	Home Health Care
	44	Home Health Visits
	45	Hospice
	46	Respite Care
	48	Hospital - Inpatient
	50	Hospital - Outpatient
	51	Hospital - Emergency Accident
	52	Hospital - Emergency Medical
	53	Hospital - Ambulatory Surgical
	54	Long Term Care
	56	Medically Related Transportation
	57	Air Transportation
	58	Cabulance
	59	Licensed Ambulance
	61	In-vitro Fertilization
	62	MRI/CAT Scan
	63	Donor Procedures
	64	Acupuncture
	65	Newborn Care
	67	Smoking Cessation
	68	Well Baby Care
	69	Maternity
	70	Transplants
	71	Audiology Exam
	72	Inhalation Therapy
	73	Diagnostic Medical
	74	Private Duty Nursing
	75	Prosthetic Device
	76	Dialysis
	77	Otological Exam
	78	Chemotherapy
	79	Allergy Testing
	80	Immunizations
	82	Family Planning
	83	Infertility
	84	Abortion
	85	AIDS
	86	Emergency Services
	93	Podiatry
	94	Podiatry - Office Visits
	95	Podiatry - Nursing Home Visits
	98	Professional (Physician) Visit - Office
	99	Professional (Physician) Visit - Inpatient
	A0	Professional (Physician) Visit - Outpatient
	A1	Professional (Physician) Visit - Nursing Home
	A2	Professional (Physician) Visit - Skilled Nursing Facility
	A3	Professional (Physician) Visit - Home
	A4	Psychiatric
	A6	Psychotherapy
	A7	Psychiatric - Inpatient
	A8	Psychiatric - Outpatient
	A9	Rehabilitation
	AB	Rehabilitation - Inpatient
	AC	Rehabilitation - Outpatient
	AD	Occupational Therapy
	AE	Physical Medicine
	AF	Speech Therapy
	AG	Skilled Nursing Care
	AI	Substance Abuse
	AJ	Alcoholism
	AK	Drug Addiction
	AL	Vision (Optometry)
	AR	Experimental Drug Therapy
	BB	Partial Hospitalization (Psychiatric)
	BC	Day Care (Psychiatric)
	BD	Cognitive Therapy
	BE	Massage Therapy
	BF	Pulmonary Rehabilitation
	BG	Cardiac Rehabilitation
	BS	Invasive Procedures

	UM04	C023	Health Care Service Location Information Description: To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered Required if the service provider�s facility type is known by the requester and UM03 does not specify a facility type. If UM03 is present and specifies a service type that is qualified by a facility type, e.g.: UM03 = A2 for Professional (Physician) Visit - Skilled Nursing Facility, do not value this field. If both UM03 and UM04 are valued and UM03 has a facility type qualifier, the value in UM03 takes precedence.	O	Comp		Situational
		1331	Facility Code Value Description: 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 Industry: Facility Type Code Use to indicate a facility code value from the code source referenced in UM04-2.	M	AN	1/2	Required

	ExternalCodeList
	Name: 236
	Description: Uniform Billing Claim Form Bill Type

	ExternalCodeList
	Name: 237
	Description: Place of Service from Health Care Financing Administration Claim Form

1332

Facility Code Qualifier
Description: Code identifying the type of facility referenced

1/2

Required

Code

Name

Uniform Billing Claim Form Bill Type

CODE SOURCE:

236: Uniform Billing Claim Form Bill Type

Place of service code from the FAO record of the Electronic Media Claims National Standard Format

CODE SOURCE:

237: Place of Service from Health Care Financing Administration Claim Form

	UM05	C024	Related Causes Information Description: To identify one or more related causes and associated state or country information Required when the patient�s condition is accident or employment related.	O	Comp		Situational
		1362	Related-Causes Code Description: Code identifying an accompanying cause of an illness, injury or an accident Industry: Related Causes Code Always use this data element if the related cause is an auto accident.	M	ID	2/3	Required

	Code	Name
	AA	Auto Accident
	AP	Another Party Responsible
	EM	Employment

1362

Related-Causes Code
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
Used if there is greater than 1 related cause for this certification.

2/3

Situational

	Code	Name
	AP	Another Party Responsible
	EM	Employment

1362

Related-Causes Code
Description: Code identifying an accompanying cause of an illness, injury or an accident
Industry: Related Causes Code
Use this code only if UM05 -1 and UM05 -2 are used.

2/3

Situational

	Code	Name
	AP	Another Party Responsible

156

State or Province Code
Description: Code (Standard State/Province) as defined by appropriate government agency
Industry: State Code
CODE SOURCE: 22: States and Outlying Areas of the U.S.
Required on review requests involving automobile accidents (UM05-1 = �AA�) if the accident occurred out of the service provider�s state.

2/2

Situational

	ExternalCodeList
	Name: 22
	Description: States and Outlying Areas of the U.S.

Country Code
Description: Code identifying the country
CODE SOURCE: 5: Countries, Currencies and Funds
Required if the automobile accident occurred out of the United States to identify the country in which the accident occurred.

2/3

Situational

	ExternalCodeList
	Name: 5
	Description: Countries, Currencies and Funds

UM06

1338

Level of Service Code
Description: Code specifying the level of service rendered
Recommended if the service requested would not be authorized unless the patient�s condition is Emergency or Urgent.

1/3

Situational

	Code	Name
	U	Urgent
	03	Emergency

UM07	1213	Current Health Condition Code Description: Code indicating current health condition of the individual Required when the patient�s condition, as expressed by the codes in this data element, is a factor in the provider�s determination of services to be performed that are not typically requested for the patient�s diagnosis and proposed treatment. All valid standard codes are used.	O	ID	1/1	Situational
UM08	923	Prognosis Code Description: Code indicating physician's prognosis for the patient Required when the patient�s prognosis, as expressed by the codes in this data element, is a factor in the provider�s determination of services to be performed that are not typically requested for the patient�s diagnosis and proposed treatment. All valid standard codes are used.	O	ID	1/1	Situational
UM09	1363	Release of Information Code Description: Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations	O	ID	1/1	Required

	Code	Name
	A	Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization
	I	Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statutes
	M	The Provider has Limited or Restricted Ability to Release Data Related to a Claim
	O	On file at Payor or at Plan Sponsor
	Y	Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim

UM10

1514

Delay Reason Code
Description: Code indicating the reason why a request was delayed
Required if the request is not submitted within the normal timeframe of the UMO.

1/2

Situational

	Code	Name
	1	Proof of Eligibility Unknown or Unavailable
	2	Litigation
	3	Authorization Delays
	4	Delay in Certifying Provider
	7	Third Party Processing Delay
	8	Delay in Eligibility Determination
	10	Administration Delay in the Prior Approval Process
	11	Other
	15	Natural Disaster
	16	Lack of Information
	17	No response to initial request

Notes:

1. Use this segment to identify the type of health care services review request.

Example:

UM*SC*I*3******Y~