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Transaction Set
in
X12 Release 008020

278 Health Care Services Review Information

Functional Group HI

X12N Insurance Subcommittee

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.

Heading

Sequence
Segment
Name
Max use
0100
Transaction Set HeaderMandatory
Max 1
To indicate the start of a transaction set and to assign a control number
0200
Beginning of Hierarchical TransactionMandatory
Max 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

Detail

Sequence
Segment
Name
Max use
2000 Loop
Repeat >1
0100
Hierarchical LevelMandatory
Max 1
To identify dependencies among and the content of hierarchically related groups of data segments
0200
Trace
Max 9
To uniquely identify a transaction to an application
0300
Request Validation
Max 9
To specify the validity of the request and indicate follow-up action authorized
0400
Health Care Services Review Information
Max 1
To specify health care services review information
0500
Health Care Services Review
Max 1
To specify the outcome of a health care services review
0600
Reference Information
Max 9
To specify identifying information
0700
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
0800
Health Care Information Codes
Max 1
To supply information related to the delivery of health care
0810
Professional Service
Max 1
To specify the service line item detail for a health care professional
0820
Institutional Service
Max 1
To specify the service line item detail for a health care institution
0830
Dental Service
Max 1
To specify the service line item detail for dental work
0840
Tooth Identification
Max 32
To identify a tooth by number and, if applicable, one or more tooth surfaces
0850
Tooth Summary
Max 35
To specify the status of individual teeth
0860
Drug Authorization
Max >1
To specify a drug for which authorization is being requested
0900
Health Care Services Delivery
Max 1
To specify the delivery pattern of health care services
1000
Conditions Indicator
Max 9
To supply information on conditions
1100
Claim Codes
Max 1
To supply information specific to hospital claims
1200
Ambulance Certification
Max 1
To supply information related to the ambulance service rendered to a patient
1300
Chiropractic Certification
Max 1
To supply information related to the chiropractic service rendered to a patient
1350
Enteral or Parenteral Therapy Certification
Max 1
To supply information regarding certification of medical necessity for enteral or parenteral nutrition therapy
1400
Oxygen Therapy Certification
Max 1
To supply information regarding certification of medical necessity for home oxygen therapy
1500
Home Health Care Certification
Max 1
To supply information related to the certification of a home health care patient
1520
Home Health Treatment Plan Certification
Max 1
To supply information related to the home health care plan of treatment and services
1530
Implant Certification
Max >1
To supply information related to medical implant registries
1550
Paperwork
Max >1
To identify the type or transmission or both of paperwork or supporting information
1600
Message Text
Max 1
To provide a free-form format that allows the transmission of text information
2010 Loop
Repeat >1
1700
Individual or Organizational Name
Max 1
To supply the full name of an individual or organizational entity
1800
Reference Information
Max 9
To specify identifying information
1900
Additional Name Information
Max 1
To specify additional names
2000
Party Location
Max 1
To specify the location of the named party
2100
Geographic Location
Max 1
To specify the geographic place of the named party
2200
Administrative Communications Contact
Max 3
To identify a person or office to whom administrative communications should be directed
2300
Request Validation
Max 9
To specify the validity of the request and indicate follow-up action authorized
2400
Provider Information
Max 1
To specify the identifying characteristics of a provider
2500
Demographic Information
Max 1
To supply demographic information
2600
Insured Benefit
Max 1
To provide benefit, characteristics, and identification information on insured entities.
2700
Date or Time or Period
Max 9
To specify any or all of a date, a time, or a time period
2800
Transaction Set TrailerMandatory
Max 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)
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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.