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278Health Care Services Review Information

This X12 Transaction Set 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.

  • ST
    Transaction Set Header
    M必须(Mandatory)
    Repeat 1

    To indicate the start of a transaction set and to assign a control number

  • BHT
    Beginning of Hierarchical Transaction
    M必须(Mandatory)
    Repeat 1

    To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time

  • HLLoop1Hierarchical Level LOOPM必须(Mandatory)Repeat > 1
    HLTRNAAAUMHCRREFDTPHISV1SV2SV3TOODN2DRAHSDCRCCL1CR1CR2CR4CR5CR6CR7CR8PWKMSGNM1Loop1
    • HL
      Hierarchical Level
      M必须(Mandatory)
      Repeat 1

      To identify dependencies among and the content of hierarchically related groups of data segments

    • TRN
      Trace
      O可选(Optional)
      Repeat 9

      To uniquely identify a transaction to an application

    • AAA
      Request Validation
      O可选(Optional)
      Repeat 9

      To specify the validity of the request and indicate follow-up action authorized

    • UM
      Health Care Services Review Information
      O可选(Optional)
      Repeat 1

      To specify health care services review information

    • HCR
      Health Care Services Review
      O可选(Optional)
      Repeat 1

      To specify the outcome of a health care services review

    • REF
      Reference Information
      O可选(Optional)
      Repeat 9

      To specify identifying information

    • DTP
      Date or Time or Period
      O可选(Optional)
      Repeat 9

      To specify any or all of a date, a time, or a time period

    • HI
      Health Care Information Codes
      O可选(Optional)
      Repeat 1

      To supply information related to the delivery of health care

    • SV1
      Professional Service
      O可选(Optional)
      Repeat 1

      To specify the service line item detail for a health care professional

    • SV2
      Institutional Service
      O可选(Optional)
      Repeat 1

      To specify the service line item detail for a health care institution

    • SV3
      Dental Service
      O可选(Optional)
      Repeat 1

      To specify the service line item detail for dental work

    • TOO
      Tooth Identification
      O可选(Optional)
      Repeat 32

      To identify a tooth by number and, if applicable, one or more tooth surfaces

    • DN2
      Tooth Summary
      O可选(Optional)
      Repeat 35

      To specify the status of individual teeth

    • DRA
      Drug Authorization
      O可选(Optional)
      Repeat > 1

      To specify a drug for which authorization is being requested

    • HSD
      Health Care Services Delivery
      O可选(Optional)
      Repeat 1

      To specify the delivery pattern of health care services

    • CRC
      Conditions Indicator
      O可选(Optional)
      Repeat 9

      To supply information on conditions

    • CL1
      Claim Codes
      O可选(Optional)
      Repeat 1

      To supply information specific to hospital claims

    • CR1
      Ambulance Certification
      O可选(Optional)
      Repeat 1

      To supply information related to the ambulance service rendered to a patient

    • CR2
      Chiropractic Certification
      O可选(Optional)
      Repeat 1

      To supply information related to the chiropractic service rendered to a patient

    • CR4
      Enteral or Parenteral Therapy Certification
      O可选(Optional)
      Repeat 1

      To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy

    • CR5
      Oxygen Therapy Certification
      O可选(Optional)
      Repeat 1

      To supply information regarding certification of medical necessity for home oxygen therapy

    • CR6
      Home Health Care Certification
      O可选(Optional)
      Repeat 1

      To supply information related to the certification of a home health care patient

    • CR7
      Home Health Treatment Plan Certification
      O可选(Optional)
      Repeat 1

      To supply information related to the home health care plan of treatment and services

    • CR8
      Pacemaker Certification
      O可选(Optional)
      Repeat 1

      To supply information related to medical implant registries

    • PWK
      Paperwork
      O可选(Optional)
      Repeat > 1

      To identify the type or transmission or both of paperwork or supporting information

    • MSG
      Message Text
      O可选(Optional)
      Repeat 1

      To provide a free-form format that allows the transmission of text information

    • NM1Loop1Individual or Organizational Name LOOPO可选(Optional)Repeat > 1
      NM1REFN2N3N4PERAAAPRVDMGINSDTP
      • NM1
        Individual or Organizational Name
        M必须(Mandatory)
        Repeat 1

        To supply the full name of an individual or organizational entity

      • REF
        Reference Information
        O可选(Optional)
        Repeat 9

        To specify identifying information

      • N2
        Additional Name Information
        O可选(Optional)
        Repeat 1

        To specify additional names

      • N3
        Party Location
        O可选(Optional)
        Repeat 1

        To specify the location of the named party

      • N4
        Geographic Location
        O可选(Optional)
        Repeat 1

        To specify the geographic place of the named party

      • PER
        Administrative Communications Contact
        O可选(Optional)
        Repeat 3

        To identify a person or office to whom administrative communications should be directed

      • AAA
        Request Validation
        O可选(Optional)
        Repeat 9

        To specify the validity of the request and indicate follow-up action authorized

      • PRV
        Provider Information
        O可选(Optional)
        Repeat 1

        To specify the identifying characteristics of a provider

      • DMG
        Demographic Information
        O可选(Optional)
        Repeat 1

        To supply demographic information

      • INS
        Insured Benefit
        O可选(Optional)
        Repeat 1

        To provide benefit information on insured entities

      • DTP
        Date or Time or Period
        O可选(Optional)
        Repeat 9

        To specify any or all of a date, a time, or a time period

  • SE
    Transaction Set Trailer
    M必须(Mandatory)
    Repeat 1

    To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Segment
X12 EDI Release 00701
STTransaction Set Header
To indicate the start of a transaction set and to assign a control number
Elements
  • ST01143Transaction Set Identifier Code
    ID
    M必须(Mandatory)
    Min 3 / Max 3

    Code identifying a Transaction Set

    Codes (320)
  • ST02329Transaction Set Control Number
    AN
    M必须(Mandatory)
    Min 4 / Max 9

    Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

  • ST031705Implementation Convention Preference
    AN
    O可选(Optional)
    Min 1 / Max 9

    Reference assigned to identify Implementation Convention

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