Health Care Services Review Information

Pos: 040

Max: 1

Detail - Optional

Loop: 2000F

Elements: 5

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 for a request regarding 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 used by the UMO in rendering a medical decision.

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 UMO. 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, value this field with the corresponding facility code value from the code source required on the claim.	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

UM06

1338

Level of Service Code
Description: Code specifying the level of service rendered
Required if used by the UMO in rendering a decision.

1/3

Situational

	Code	Name
	U	Urgent
	03	Emergency

Notes:

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

Example:

UM*SC*I*3~