EDI 278-A1 Health Care Services Review – Request for Review
The EDI 278-A1 transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of a 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.
EDI 278-A1 may relate to services to be administered by the healthcare service provider, or for referring an individual to another provider. A single 278 is commonly used for one patient and one patient event. The Health Care Services Review document was chosen by HIPAA as the standard format for EDI transmission of authorizations and referrals. This is an important issue of patient privacy, as 278 documents typically contain healthcare related data, such as patient, diagnosis or treatment information.
EDI 278-A1 Format Example
Referral – Request for Review
ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
The following example represents the Request for Review (Specialty Care Referral) from Dr. Gardener to Maryland Capital Insurance.
|ST*278*0001*005010X217~||Begin transaction set 278, control #0001, and implementation convention reference is 005010X217.|
|BHT*0007*13*A12345*20050502*1101~||This transaction is a request using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier “A12345″ along with the transaction set creation date and time.|
Loop 2000A hierarchical level identifies the Insurance Company.
|HL*1**20*1~||HL count is 1. There is no higher, or parent, HL. This HL code is 20, identifying the information source or the insurance company. This HL has subordinate levels, or children.|
|NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~||The request for a referral is being made to Maryland Capital Insurance Company. Their electronic transmitter identification number is 789312.|
Loop 2000B hierarchical level identifies the submitting provider.
|HL*2*1*21*1~||HL count is 2. This HL is subordinate to HL*1, the parent HL. This HL code is 21, identifying the information receiver or the referring provider. This HL has subordinate levels, or children.|
|NM1*1P*1*GARDENER*JAMES****46*8189991234~||The request is being made by James Gardener whose Electronic Transmitter Identification Number is 8189991234.|
Loop 2000C hierarchical level identifies the subscriber, who in this case is also the patient.
|HL*3*2*22*1~||HL count is 3. This HL is subordinate to HL*2, the parent HL. This HL code is 22, identifying the subscriber. This HL has subordinate levels, or children.|
|NM1*IL*1*SMITH*JOE****MI*12345678901~||The patient’s name is Joe Smith; his Member Identification Number is 12345678901.|
Loop 2000D hierarchical level identifies the dependent as a patient.
Because there is no dependent in this example, there is no Loop 2000D.
Loop 2000E hierarchical level identifies the patient event.
|HL*4*3*EV*0~||HL count is 4. This HL is subordinate to HL*3, the parent HL. This HL code is EV, identifying the patient event. This HL has no subordinate levels, or children.|
|TRN*1*111099*9012345678~||The provider assigned the trace number 111099 to this service request. The requester has included the user-assigned identifier of 012345678 to this trace number.|
|UM*SC*I*3*11:B*****Y~||Dr. Gardener is requesting an initial consultation for the patient.|
|HI*BF:41090:D8:20050430~||The patient has been diagnosed with acute myocardial infarction; unspecified site.|
|HSD*VS*1~||Dr. Gardener is requesting a single visit.|
|NM1*SJ*1*WATSON*SUSAN****34*987654321~||The patient event provider is identified as Susan Watson. Her Social Security Number is 987654321.|
|PER*IC**TE*4029993456~||Dr. Watson can be contacted by telephone at (402)999-3456.|
|SE*16*0001~||Number of segments, control number.|
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples
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