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Segment
in
X12 Release 008010

UM Health Care Services Review Information

To specify health care services review information
Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
1525
Request Category Code
Identifier (ID)
Mandatory
1
2
1
Code indicating a type of request
Codes (7)
02
Certification Type Code
Identifier (ID)
Optional
1
1
1
Code indicating the type of certification
Codes (17)
03
Industry Code
String (AN)
Optional
1
30
1
Code indicating a code from a specific industry code list
UM03 is the Service Type (Code Source 958).
04
Health Care Service Location Information
Composite (composite)
Optional
1
01
Facility Code Value
String (AN)
Mandatory
1
3
-
Code identifying where services were, or may be, performed; the National Uniform Billing Committee (NUBC) Facility Type Code for Institutional Services or the Place of Service Codes for Professional or Dental Services.
C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
02
Facility Code Qualifier
Identifier (ID)
Mandatory
1
2
-
Code identifying the type of facility referenced
C023-02 qualifies C023-01.
Codes (2)
03
Claim Frequency Type Code
Identifier (ID)
Optional
1
1
-
Code specifying the Type of Bill Frequency Code. It is the last digit of Type of Bill in the UB manual, as defined by the National Uniform Billing Committee
05
Related Causes Information
Composite (composite)
Optional
1
01
Related-Causes Code
Identifier (ID)
Mandatory
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
02
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
03
Related-Causes Code
Identifier (ID)
Optional
2
3
-
Code identifying an accompanying cause of an illness, injury or an accident
Codes (6)
04
State or Province Code
Identifier (ID)
Optional
2
2
-
Code specifying the Standard State/Province as defined by appropriate government agency
C024-04 and C024-05 apply only to auto accidents when C024-01, C024-02, or C024-03 is equal to "AA".
05
Country Code
Identifier (ID)
Optional
2
3
-
Code identifying the country
06
Level of Service Code
Identifier (ID)
Optional
1
3
1
Code specifying the level of service rendered
Codes (19)
07
Current Health Condition Code
Identifier (ID)
Optional
1
1
1
Code indicating current health condition of the individual
Codes (13)
08
Prognosis Code
Identifier (ID)
Optional
1
1
1
Code indicating physician's prognosis for the patient
Codes (8)
09
Release of Information Code
Identifier (ID)
Optional
1
1
1
Code indicating whether the provider has on file a signed statement by the patient authorizing the release of medical data to other organizations
Codes (6)
10
Delay Reason Code
Identifier (ID)
Optional
1
2
1
Code indicating the reason why a request was delayed
Codes (14)
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Stedi is a registered trademark of Stedi, Inc. Stedi's EDI Reference and Mapping Guides are provided for marketing purposes and are free of charge. All names, logos, and brands of third parties listed on our site are trademarks of their respective owners (including “X12”, which is a trademark of X12 Incorporated). Stedi, Inc. and its products and services are not endorsed by, sponsored by, or affiliated with these third parties. Our use of these names, logos, and brands is for identification purposes only, and does not imply any such endorsement, sponsorship, or affiliation.