HCR

Health Care Services Review

Pos: 050	Max: 1
Detail - Optional
Loop: 2000F	Elements: 4

Ref

Id

Element Name

Req

Type

Min/Max

Usage

HCR01

306

Action Code
Description: Code indicating type of action
Alias: Certification Action Code

M

ID

1/2

Required

Code

Name

A1

Certified in total

A3

Not Certified

A4

Pended

A6

Modified

CT

Contact Payer

NA

No Action Required

Use only if certification is not required.

HCR02

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Certification Number
Required if HCR01 = A1 or A6.

O

AN

1/30

Situational

HCR03

901

Reject Reason Code
Description: Code assigned by issuer to identify reason for rejection
Required if HCR01 = A3 or A4. Use to indicate the primary reason for the code assigned in HCR01.

O

ID

2/2

Situational

Code

Name

35

Out of Network

36

Testing not Included

37

Request Forwarded To and Decision Response Forthcoming From an External Review Organization

41

Authorization/Access Restrictions

Use to indicate that the service requested requires PCP authorization.

53

Inquired Benefit Inconsistent with Provider Type

69

Inconsistent with Patient's Age

70

Inconsistent with Patient's Gender

82

Not Medically Necessary

83

Level of Care Not Appropriate

84

Certification Not Required for this Service

85

Certification Responsibility of External Review Organization

86

Primary Care Service

87

Exceeds Plan Maximums

88

Non-covered Service

Use for services not covered by the patient’s plan such as Worker’s Compensation or Auto Accident.

89

No Prior Approval

90

Requested Information Not Received

Use with HCR01 = A4 to indicate that the review outcome is pending additional medical necessity information.

91

Duplicate Request

92

Service Inconsistent with Diagnosis

96

Pre-existing Condition

98

Experimental Service or Procedure

E8

Requires Medical Review

Use to indicate that a review by medical personnel is necessary.

HCR04

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Second Surgical Opinion Indicator
Use when certification pertains to a surgical procedure and thecontract under which the patient is covered has provisions regarding a second surgical opinion.

O

ID

1/1

Situational

Code

Name

N

No

Y

Yes

1.

HCR02 is the number assigned by the information source to this review outcome.

2.

HCR04 is the second surgical opinion indicator. A "Y" value indicates a second surgical opinion is required; an "N" value indicates a second surgical opinion is not required for this request.

Notes:

1. Use this segment to provide review outcome information and an associated reference number.
2. Required if the UMO has reviewed the request. If the UMO was unable to review the request due to missing or invalid application data at this level, the UMO must return a 278 response containing a AAA segment at this level.
3. If Loop 2000F is present, either the AAA segment or the HCR segment must be returned.
4. If the review outcome is pending additional medical information and the 278 response includes a request for additional information using either a PWK segment or an HI segment that specifies LOINC values, then the associated HCR segment must be valued with HCR01 = A4 (pended) and HCR03 = 90 (Requested Information Not Received)
Refer to Section 2.2.5 for more information.

Example:

HCR*A1*19950713~