EDI 278 Healthcare Services Review – Request for Review
What is the EDI 278 Transaction Set?
The EDI 278 Healthcare Services Review Information transaction set and format have been specified by HIPAA 5010 standards for the electronic exchange for transmission of claims status review information. Users of this transaction set include payors, plan sponsors, providers, utilization management, and other entities involved in healthcare services review. The EDI 278 transaction set and format can be a one-way transaction or a two-way “inquiry/response” transaction. It can be used to transmit healthcare 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 healthcare services review.
Note that a single EDI 278 is commonly used for one patient and one patient event. This is in contrast to other EDI HIPAA 5010 healthcare transactions where multiple plan subscribers or patients may be processed.
The EDI 278 A1 transaction set can be used to transmit healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data. The purpose of the transaction can be a request for review, certification, notification or reporting the outcome of a healthcare services review.
EDI 278 Services Review Request in Data Mapper
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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 Healthcare 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.
Transmission Explanation
Table 1
| 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 trace number 111099 to this service request. The requester has included the user-assigned identifier of 012345678 in 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. |
Source
Accredited Standards Committee X12. ASC X12 Standard [Table Data]. Data Interchange Standards Association, Inc., McLean, VA. ASC X12 Examples
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.