EDI 278 Healthcare Services Review – Response to a 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 may be either a one-way transaction or a two-way “inquiry/response” transaction. Note that a single 278 is commonly used for one patient and one patient event.
The EDI 278 A3 transaction set can be used to respond to requests for healthcare service information, such as subscriber, patient, demographic, diagnosis or treatment data. The purpose of the EDI 278 A3 transaction type can be a request for review, certification, notification or reporting the outcome of a healthcare services review.
EDI 278 Services Review Response in Data Mapper
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EDI 278 A3 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 Response document was chosen by HIPAA as the standard format for responses to 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 A3 Format Example
Referral – Response to the Request for Review
ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
The following example represents the response to a request for review from Maryland Capital Insurance to Dr. Gardener. In this case, Maryland Capital Insurance has approved the referral request with no modifications.
Notice that the response transaction includes the detail of the request transaction to ensure for all parties exactly what is being approved. Notice that the insurance company has included a certification number for reference, AUTH0001. Also, note the use of the DTP segment to specify the time period during which the referral is valid, and the service is to be performed.
|ST*278*0001*005010X217~||Begin transaction set 278, control #0001, and implementation convention reference is 005010X217.|
|BHT*0007*11*A12345*20050502*1102*18~||This transaction is a response using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The UMO’s system returns the Submitter Transaction Identifier “A12345. The BHT06 value of ”18″ indicates that this is a response with no further updates to follow.|
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 response to the request for a referral is being made by 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 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*2*111099*9012345678~||The UMO must return the trace number assigned by the provider to aid the provider in linking this response to the original request.|
|UM*SC*I*3*11:B~||Dr. Gardener requested an initial consultation for the patient with Dr. Watson at Dr. Watson’s office.|
|HCR*A1*AUTH0001~||Maryland Capital approves the referral and provides a certification number.|
|DTP*AAH*RD8*20050502-20050602~||The insurance company indicates a date range during which the consultation or service can occur.|
|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*18*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
X12, chartered by the American National Standards Institute for more than 35 years, develops and maintains EDI standards and XML schemas.