New: Drop-in replacement for Change Healthcare APIs

EDI 274 Healthcare Provider Information

Functional Group PW

X12N Insurance Subcommittee

This X12 Transaction Set contains the format and establishes the data contents of the Healthcare Provider Information Transaction Set (274) for use within the context of an Electronic Data Interchange (EDI) environment. This standard can be used to exchange demographic and educational/professional qualifications about healthcare providers between providers, provider networks or any other entity that maintains or verifies healthcare provider information. Such exchanges include the transmitting, inquirying, or responding to an inquiry. Healthcare provider information is routinely exchanged for the purpose of 1) maintaining provider data bases for claim adjudication, provider directories, patient referrals, and reporting provider information, 2) submitting an application to join a provider organization or provider network such as, but not limited to, a hospital, preferred provider organization (PPO) or health maintenance organization (HMO), and 3) verifying credentials such as educational/professional qualifications, licenses, and malpractice coverage/history.

Heading

Position
Segment
Name
Max use
  1. To indicate the start of a transaction set and to assign a control number

  2. 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

  3. To specify pertinent dates and times

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

    The PER segment is used to supply the sender's point of contact to the receiver.

Detail

Position
Segment
Name
Max use
  1. 2000 Loop Mandatory
    Repeat >1
    1. To identify dependencies among and the content of hierarchically related groups of data segments

      Valid hierarchical level codes for this transaction set are information source, information receiver, provider, group and site of service.
    2. To uniquely identify a transaction to an application

      The TRN segment is used to identify trace numbers that provide an electronic link between this transaction and other transactions.
    3. To specify the validity of the request and indicate follow-up action authorized

    4. 2100 Loop Mandatory
      Repeat >1
      1. To supply the full name of an individual or organizational entity

        The NM1 segment is used to identify individuals and entities related to the hierarchical level identified by HL03.
      2. To specify additional names

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

      4. To supply demographic information

      5. To indicate the total monetary amount

      6. To provide information on activity or process

      7. To provide information about an educational institution's academic award

      8. To provide additional demographic information to the receiving school, institution, or agency to assist in identifying the particular student

      9. To specify language, type of usage, and proficiency or fluency

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

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

      12. To specify textual data

      13. To specify quantity information

      14. To specify an individual's work schedule

      15. To supply information on conditions

      16. To specify the delivery pattern of health care services

      17. To identify information basic to the processing of any claims transaction

      18. To provide detail information on a health care provider's practice

      19. To provide detail information describing a provider's affiliation to a specific hospital

      20. 2110 Loop Optional
        Repeat >1
        1. To define the attributes of a property or an entity

          Loop 2110 provides multiple addresses related to the entity identified in the NM1 segment. The NX1 segment provides the type of address for each iteration of the loop. For instance, billing service or place of business.
        2. To specify additional names

        3. To specify the location of the named party

        4. To specify the geographic place of the named party

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

      21. 2120 Loop Optional
        Repeat >1
        1. To identify standard industry codes

        2. To identify a party by type of organization, name, and code

        3. To identify title of an individual within a company

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

        5. To specify quantity information

        6. To identify and answer yes and no questions, including the date, time, and comments further qualifying the condition

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

      22. 2130 Loop Optional
        Repeat 99
        1. To provide license, certification, accreditation, and registration information for health care providers

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

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

      23. 2140 Loop Optional
        Repeat >1
        1. To specify identifying information

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

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

      24. 2150 Loop Optional
        Repeat 9
        1. To describe employment position

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

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

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