278 Health Care Services Review - Inquiry and Response (008020X327)

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

Code identifying a group of application related transaction sets

This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.

CODE

DEFINITION

Health Care Services Review Information (278)

Required

142

Application Sender's Code

M 1

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

Code identifying party receiving transmission; codes agreed to by trading partners

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: GS04 is the group date.

Use this date for the functional group creation date.

Required

337

Time

M 1

4/8

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

SEMANTIC: GS05 is the group time.

Use this time for the creation time. The recommended format is HHMM.

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.

For implementations compliant with this guide, GS06 must be unique within a single transmission (that is, within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender.

Required

455

Responsible Agency Code

M 1

1/2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

1/12

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

INDUSTRY NAME: Version, Release, or Industry Identifier Code

This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.

CODE SOURCE 881: Version / Release / Industry Identifier Code

CODE

DEFINITION

008020X327

Health Care Services Review - Inquiry and Response

ST*278 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the start of a Healthcare Services Review Inquiry transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based Utilization Management review inquiry.

TR3 Example:

ST✱278✱0002✱008020X327~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code identifying a Transaction Set

SEMANTIC: The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).

CODE

DEFINITION

278

Health Care Services Review Information

Required

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The Transaction Set Control Numbers in ST02 and SE02 must be identical and must be a numeric value. The number (i.e. numeric value) is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the numeric value 0001 and increment from there. The Transaction Set Control Number also aids in error resolution research.

Required

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

SEMANTIC: The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.

This element must be populated with the guide identifier named in Section 1.2.
This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

CODE

DEFINITION

008020X327

Health Care Services Review - Inquiry and Response

BHT*0007 - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BHT✱0007✱28✱199800114000001✱20220101✱1400✱RD~

BHT

✱

✱

✱

✱

✱

✱

Transaction
Type Code

Loop 2000A - UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL

Required

1005

Hierarchical Structure Code

M 1

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

Used to specify the sequential order of HL segments. The HL loops in the data stream must comply with this sequential order. An HL parent loop must be followed by any subordinate child loops prior to commencing a new HL parent loop at the same hierarchical level.

CODE

DEFINITION

0007

Information Source, Information Receiver, Subscriber, Dependent, Event, Services

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Query

Use when inquiring on authorizations associated with a specific patient.

Historical Inquiry

Use when the transaction is a global inquiry for the status of authorizations associated with multiple patients.

Required

127

Reference Identification

O 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

INDUSTRY NAME: Submitter Transaction Identifier

Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. If the inquiry transaction is processed in real-time, the respondent must return this value in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of real-time 278 inquiry transactions are required to return the Submitter Transaction Identifier in their 278 response.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

373

Date

O 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: BHT04 is the date the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Date

Required

337

Time

O 1

4/8

SEMANTIC: BHT05 is the time the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Time

Situational

640

Transaction Type Code

O 1

Code specifying the type of transaction

SITUATIONAL RULE: Required when BHT02 = 51 and the requester has a preference for full detail or summary responses. If not required by this implementation guide, do not send.

This implementation guide does not require the UMO system to support both summary and detail responses. Refer to Section 1.11.5 for a description of the contents of these responses.

CODE

DEFINITION

Returns Detail

Use when requesting the full details for the available records on the UMO system based on the search criteria provided.

Sort and Segregate Detail

Use when requesting a summary of information for the available records on the UMO system based on the search criteria provided.

HL - UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the information source hierarchical level. For an inquiry transaction, this segment identifies the payer, HMO, or other utilization management organization that is the source of service review decision.

TR3 Example:

HL✱1✱✱20✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

COMMENT: HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Not Used

734

Hierarchical Parent ID Number

O 1

1/12

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.

CODE

DEFINITION

Information Source

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop 2010A - UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the source of information. For an inquiry transaction this names the payer or utilization review organization responsible for the health care service review decision.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~

NM1

✱

✱

Loop 2000B - REQUESTER LEVEL

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Third-Party Administrator

Employer

Payer

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the reviewing entity is an individual (NM102 = 1), such as a primary care provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Name Suffix

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use when UMO is a payer and XV is not used.

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

Use when the provider is in the United States or its territories and is eligible to receive a National Provider Identifier (NPI).
OR
Use when the provider is not in the United States or its territories and has received an NPI.

CODE SOURCE: 537: National Provider Identifier (NPI)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Utilization Management Organization (UMO) Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

HL - REQUESTER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment indicates the healthcare services review information receiver. For inquiry transactions, this corresponds to the identification of the entity initiating the inquiry.

TR3 Example:

HL✱2✱1✱21✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1 - REQUESTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment identifies the entity requesting the service review information.

TR3 Example:

NM1✱1P✱1✱WHITE✱CHRIS✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Federal, State, County or City Facility

Third-Party Administrator

Employer

Facility

Payer

Utilization Management Organization

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the requester. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is present and NM102 = 1. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Payor Identification

Use when UMO is a payer and XV is not used.

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when requesting the services of a specific person, facility, group practice, or clinic and the provider NPI is known by the requester. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - REQUESTER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Use when reporting the physician, clinic, or group practice.

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Use when reporting a Social Security Number.

The Social Security Number must be a string of exactly nine numbers with no separators.

For example, sending "111002222" would be valid, while sending "111-00-2222" would be invalid.

Carrier Assigned Reference Number

Use when reporting the requester/provider ID as assigned by the UMO identified in Loop 2000A.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Requester Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - REQUESTER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.

TR3 Notes:

Use to identify a specific location when the requester has multiple locations and authority varies based on location.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Requester Address Line

Use this element for the first line of the requester's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Address Line

N4 - REQUESTER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Requester City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

COMMENT: N403 contains the postal code in an unstructured format. N408 contains the postal code in a structured format. When a postal code data field is used, the parties shall agree as to which data element (N403 or N408) shall be used in the transaction set.

SEGMENT SYNTAX: E0308

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

SITUATIONAL RULE: Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PRV - REQUESTER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop 2000C - SUBSCRIBER LEVEL

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when inquiring on the status of authorizations for a specific patient. If not required by this implementation guide, do not send.

TR3 Notes:

The Subscriber Hierarchical level (Loop 2000C) is required if the inquiry concerns authorizations for a specific patient. Situational use of this segment enables the requester to create an inquiry that does not specify the name or member information for each patient. If the requester omits this loop on the inquiry, the requester can inquire on the status of all the health care services review requests for which the provider is the original requesting provider, the patient event/service provider, or primary care provider of record for the patient(s).

For the UMO to respond to this type of inquiry, the UMO must provide other methods of access to authorizations on file in addition to access by member ID. This guide does not require UMOs to support this level of inquiry. Support at this level is at the discretion of the UMO. The UMO must authenticate that the entity initiating the inquiry has a relationship with this patient that authorizes the requester to receive this information.
This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.
A transaction submitted in real-time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.
Patient Event Loop 2000E must be valued if Loop 2000C is not valued.

TR3 Example:

HL✱3✱2✱22✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*IL - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name and identification number of the subscriber (who may also be the patient), or the Property & Casualty (including Workers' Compensation) entity.
The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows:
Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02)
Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.
When a Property & Casualty (including Workers' Compensation) entity is the Subscriber, value the Entity Type Qualifier to 2 and the associated Federal Tax ID.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Insured or Subscriber

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber and the middle name/initial of the subscriber is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Middle Name or Initial

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when subscriber's military title or rank is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the suffix of an individual's name is needed to further identify the subscriber; e.g., Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when NM102 = 2.

Standard Unique Health Identifier for each Individual in the United States

Use when reporting the "HIPAA Individual Identifier" once this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

Member Identification Number

Use when reporting the subscriber's identification number as assigned by the payer.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - SUBSCRIBER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.

TR3 Notes:

Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is provided in the NM1 segment as a Member Identification Number when it is the primary number by which the UMO knows the member (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless it is different from the Member Identification Number provided in the NM1 segment.
If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱1W✱123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Use when you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

Branch Identifier

Group Number

Department Number

Patient Account Number

Use when reporting the patient account number. The maximum number of characters to be supported in REF02 for this qualifier is '35'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Health Insurance Claim (HIC) Number

Identity Card Number

Use when the Identity Card Number differs from the Member Identification Number (MI) in NM108.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DMG*D8 - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the subscriber/patient. If not required by this implementation guide, do not send.

TR3 Notes:

Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19580322~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Subscriber Birth Date

Not Used

1068

Gender Code

O 1

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 25

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

INS*Y - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when subscriber's military role is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~

INS

✱

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

✱

584

Employment
Status Code

✱

✱

✱

1250

✱

✱

✱

✱

✱

✱

✱

Chge Identi
Info Code

O 20

✱

1793

Prov Netwrk
Info Code

Loop 2000D - DEPENDENT LEVEL

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Self

Not Used

875

Maintenance Type Code

O 1

Not Used

1203

Maintenance Reason Code

O 1

2/3

Not Used

1216

Benefit Status Code

O 1

Not Used

C052

Medicare Status Code

O 1

Not Used

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

Required

584

Employment Status Code

O 1

Code indicating the general employment status of an employee/claimant

Use to qualify the patient's relationship to the military.

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

Not Used

1220

Student Status Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Not Used

1165

Confidentiality Code

O 1

Not Used

City Name

O 1

2/30

Not Used

156

State or Province Code

O 1

Not Used

Country Code

O 1

2/3

Not Used

1470

Number

O 1

1/9

Not Used

1792

Changed Identifying Information Code

O 20

1/2

Not Used

1793

Provider Network Status Information Code

O 1

1/2

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when inquiring on the status of authorizations for a specific patient who is someone other than the subscriber and the patient does not have a unique (different from the subscriber) member ID. If not required by this implementation guide, do not send.

TR3 Notes:

If the patient has a unique member ID, use Loop 2000C to identify the patient.
A transaction submitted in real-time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.

TR3 Example:

HL✱4✱3✱23✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

NM1*QC - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop 2010D - DEPENDENT NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment conveys the name of the dependent who is the patient.
The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02)
Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~

NM1

✱

✱

Loop 2010D - DEPENDENT NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Patient

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent and the middle name/initial of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when name information is needed to identify the Dependent and the suffix of an individual's name; e.g. Sr., Jr., or III of the dependent is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Name Suffix

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - DEPENDENT SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when used by the requester to identify the dependent to the UMO. If not required by this implementation guide, do not send.

TR3 Notes:

Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.
If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱EJ✱660415~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Employee Identification Number

Patient Account Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DMG*D8 - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop 2010D - DEPENDENT NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when birth date is needed to identify the dependent. If not required by this implementation guide, do not send.

TR3 Notes:

Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19580322~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Dependent Birth Date

Not Used

1068

Gender Code

O 1

Not Used

1067

Marital Status Code

O 1

Not Used

C056

Composite Race or Ethnicity Information

X 25

Not Used

1066

Citizenship Status Code

O 1

1/2

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

HL - PATIENT EVENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

This loop is required when (1) this is a global inquiry and the Patient loop (2000C or 2000D) is not valued, or when (2) the requester wants to limit the inquiry to service reviews for a specific patient event or patient event provider associated with the patient identified, or when (3) this is a patient inquiry and the Service loop (2000F) is not valued. If not required by this implementation guide, do not send.

TR3 Notes:

The Patient Event level enables you to further qualify your inquiry. Use this loop to identify an existing patient event level authorization associated with this inquiry.
When you use this loop on the inquiry, you limit the range of authorizations that meet the specifications entered. Use of this loop also ensures that the response from the UMO contains only those authorizations that meet the criteria you provided.
A transaction submitted in real time mode can contain a maximum of one global inquiry. A transaction submitted in batch mode can contain a maximum of five global inquiries. Refer to section 1.4.2 for a description of global inquiry.

TR3 Example:

HL✱5✱4✱EV✱1~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

INDUSTRY NAME: Hierarchical Parent ID Number

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

INDUSTRY NAME: Hierarchical ID Number

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Event

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

TRN*1 - PATIENT EVENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to assign a unique trace number to track this inquiry at the Patient Event level. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

TR3 Notes:

Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Patient Event Trace Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.
The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

SITUATIONAL RULE: Required when the requester needs to identify a specific component, such as a specific division or group, of the company identified in the previous data element (TRN03). If not required by this implementation guide, do not send.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester wants to identify the request category, certification type code, service type, or service location of health care service review of the inquiry. If not required by this implementation guide, do not send.

TR3 Notes:

Value this segment if you want to limit the inquiry to only referrals, or admission certifications, or health care service certifications.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

Certificate
Type Code

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Use when limiting the inquiry to information on requests for admission to a facility.

Health Services Review

Use when reporting services related to an episode of care.

Individual

Use when reporting on the status or existence of service reservations.

Specialty Care Review

Use when reporting a referral to a specialty provider.

Situational

1322

Certification Type Code

O 1

Code indicating the type of certification

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to service review requests that were submitted with a specific certification type code. If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

Use when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Use when requesting the UMO to reconsider a previously denied referral or certification.

Renewal

Use when various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

Revised

Use when changing the specifics of a previously submitted request for which services have not been rendered.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to only those authorizations for the type of service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

Situational

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

X12 COMPOSITE SEMANTIC NOTES:

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
C023-02 qualifies C023-01.

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to only those certifications for the facility type specified. If not required by this implementation guide, do not send.

Use of this element assumes that the original health care services review request specified the same facility type. Note that the original health care services review request might have specified a different facility type or expressed the facility as part of the service type in UM03. Use of this element implies that only those certifications with an exact match on this value are returned by the UMO.

Required

4-1

1331

Facility Code Value

M 1

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.

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE: 237: Place of Service Codes for Professional Claims

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to only those health care service reviews on file at the UMO with a specific status. If not required by this implementation guide, do not send.

TR3 Notes:

Use of HCR01 (action code) to limit the responses to only those authorizations that match a specific action/status may omit authorizations for which the status has changed. For example, an inquiry on all health care services reviews with a pended status will not return information on a review that has moved from a pended to a final status.

TR3 Example:

HCR✱A1~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

Certification Action Code

CODE

DEFINITION

Complete

Use when the inquiry is for authorizations with a status of complete. For the UMO, the authorization is complete at the time the claim is received and recorded.

Term Expired

Use when the inquiry is for authorizations with a status of expired.

Certified in total

Certified - partial

Use when the inquiry is for authorizations with a status of partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Not Certified

Pended

Modified

Cancelled

Contact Payer

Not Used

127

Reference Identification

O 1

1/80

Not Used

1271

Industry Code

O 5

1/30

Not Used

1073

Yes/No Condition or Response Code

O 1

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on a previously authorized health care service review or on authorizations associated with a previously authorized health care service review and the authorization number previously assigned by the UMO is known. If not required by this implementation guide, do not send.

TR3 Notes:

This is the certification number previously assigned by the UMO to the original service review outcome associated with this inquiry. This is not the trace number assigned by the requester.
If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on a previous health care services review request for which the UMO has returned a response that contained an administrative reference number in the REF segment where REF01 = NT and did not return a certification number in HCR02. If not required by this implementation guide, do not send.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*439 - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to authorizations for patient events associated with a specific accident date, or when this is a global inquiry and none of the other DTP segments in this loop are valued. If not required by this implementation guide, do not send.

TR3 Notes:

A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱439✱D8✱20221030~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Accident Date

DTP*AAH - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to service reviews for patient events scheduled for a specific proposed or actual patient event date or date range. If not required by this implementation guide, do not send.

TR3 Notes:

If UM01 = AR use Admit Date.
A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱AAH✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AAH

Event

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Event Date

DTP*435 - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to health care service reviews for admission to a facility for a specific proposed or actual admission date. If not required by this implementation guide, do not send.

TR3 Notes:

Use in conjunction with UM01 = "AR" (admission review) to limit the inquiry to patient events associated with requests for admission to a facility.
A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱435✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

435

Admission

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use when needed to report a range of dates when admission can occur.

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Admission Date

DTP*096 - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to admission reviews (UM01 = "AR") with an associated proposed or actual date of discharge. If not required by this implementation guide, do not send.

TR3 Notes:

A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱096✱D8✱20220930~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Discharge Date

DTP*102 - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to those authorizations issued on a specific date or within a specific date range. If not required by this implementation guide, do not send.

TR3 Notes:

A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱102✱D8✱20221002~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to authorizations that expire on or by a specific date or within a specific date range. If not required by this implementation guide, do not send.

TR3 Notes:

A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱036✱D8✱20221002~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Expiration Date

DTP*007 - CERTIFICATION EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Notes:

A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Effective Date

DTP*881 - HEALTH CARE SERVICES REVIEW REQUEST DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to service reviews requested on a specific date or date range, or when this is a global inquiry and none of the other DTP segments in this loop are valued and the Service Date DTP in Loop 2000F is not valued. If not required by this implementation guide, do not send.

TR3 Notes:

The date when the requester initiated the health care services review request might not be consistent with the date when the UMO received the health care services review request. Use of this segment implies that only those certifications that match on this value are returned by the UMO.
A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱881✱D8✱20221223~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

881

Request

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Health Care Services Review Request Date

HI - PATIENT SYMPTOMS, DIAGNOSIS, COMPLAINTS

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to authorizations related to a specific diagnosis associated with a single episode of care. If not required by this implementation guide, do not send.

TR3 Notes:

Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
There are 2 repetitions of the HI segment to allow for 24 possible occurrences of ICD Diagnosis code information. The first iteration would contain diagnosis code 1-12. When used, the second iteration would contain diagnosis codes 13-24.

TR3 Example:

HI✱ABF:H16013~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABJ

International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Diagnosis Related Group (DRG)

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

Not Used

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1-4

1251

Date Time Period

X 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

Not Used

1-10

1271

Industry Code

O 1

1/30

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

NM1 - PATIENT EVENT PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to authorizations for patient event providers other than or in addition to the provider identified in the Loop 2010B, or limit the inquiry to authorizations for a specialty entity for this patient event. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Attending Physician

Operating Physician

Other Physician

Service Location

Admitting Physician

Assistant Surgeon

Ordering Physician

Referring Provider

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when identifying a specific person, facility, group practice, or clinic and NM108/NM109 are not present. Not used if identifying a specialty entity utilizing the PRV segment. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.

INDUSTRY NAME: Patient Event Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when requesting the services of a specific person, facility, group practice, or clinic and the provider ID is known by the requester. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when the event provider has not been assigned an NPI and the UMO identified in loop 2010A has assigned its own identifier for this provider.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Event Provider Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

352

Description

X 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See Code Source 22: State and Outlying Areas of the US.

Not Used

C040

Reference Identifier

O 1

N3 - PATIENT EVENT PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to authorizations for a patient event location and the patient event provider has multiple locations to identify the specific location. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Address Line

Use this element for the first line of the provider's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Address Line

N4 - PATIENT EVENT PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Patient Event Provider City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Patient Event Provider Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Patient Event Provider Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

HL - SERVICE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
The HL segment defines a top-down/left-right ordered structure.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the Patient Event loop is not valued or when inquiring on authorizations for specific services or procedures. If not required, by this implementation guide, do not send.

TR3 Example:

HL✱6✱5✱SS✱0~

✱

✱

✱

✱

Required

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

INDUSTRY NAME: Hierarchical Parent ID Number

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

Required

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

INDUSTRY NAME: Hierarchical ID Number

Required

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Services

Required

736

Hierarchical Child Code

O 1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

TRN*1 - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to track this inquiry at the Service level. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.

TR3 Notes:

Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.
If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.

TR3 Example:

TRN✱1✱111099✱9012345678✱RADIOLOGY~

TRN

✱

✱

✱

Originating
Company ID

✱

Required

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

Required

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Service Trace Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

509

Originating Company Identifier

O 1

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.

The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.

Situational

127

Reference Identification

O 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester wants to limit the inquiry to a specific service type or procedure and the associated request category, certification type code, service type, or service location differs from the information specified in the UM segment at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

Value this segment if you want to limit the inquiry to only referrals or only health care service certifications.

TR3 Example:

UM✱SC✱I✱3~

✱

✱

Certificate
Type Code

✱

✱

Health Care
Serv Loc.

✱

✱

✱

✱

✱

✱

Required

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Use when reporting services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

Situational

1322

Certification Type Code

O 1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

Use when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Use when requesting the UMO to reconsider a previously denied referral or certification.

Renewal

Revised

Use when changing the specifics of a previously submitted request for which services have not been rendered.

Situational

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to authorizations for a specific service type and that service type is different from the UM03 value at the Patient Event level (Loop 2000E) and is not expressed as a specific code value in the SV1, SV2, or SV3 segment in this Service loop. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

Situational

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

X12 COMPOSITE SEMANTIC NOTES:

C023-01 does not contain the last position of the Uniform Bill Type Code (the Claim Frequency Code).
C023-02 qualifies C023-01.

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to only those authorizations for services at the facility type specified and that facility type is different from the value specified in the Patient Event loop UM04. If not required by this implementation guide, do not send.

For this service, values at the Service Level override values at the Patient Event Level.
Use of this element assumes that the original health care services review request specified the same facility type. Note that the original health care services review request might have specified a different facility type or expressed the facility as part of the service type in UM03. Use of this element implies that only those authorizations with an exact match on this value are returned by the UMO.

Required

4-1

1331

Facility Code Value

M 1

1/3

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

Required

4-2

1332

Facility Code Qualifier

M 1

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE: 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE: 237: Place of Service Codes for Professional Claims

Not Used

4-3

1325

Claim Frequency Type Code

O 1

Not Used

C024

Related Causes Information

O 1

Not Used

1338

Level of Service Code

O 1

1/3

Not Used

1213

Current Health Condition Code

O 1

Not Used

923

Prognosis Code

O 1

Not Used

1363

Release of Information Code

O 1

Not Used

1514

Delay Reason Code

O 1

1/2

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to only those authorizations for a service with a specific status such as "term expired" and that status is different from the value in HCR01 at the Patient Event Level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

HCR✱A1~

HCR

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Complete

Use when the inquiry is for authorizations with a status of complete. For the UMO, the authorization is complete at the time the claim is received and recorded.

Term Expired

Use when the inquiry is for authorizations with a status of expired.

Certified in total

Not Certified

Pended

Modified

Cancelled

Contact Payer

Not Used

127

Reference Identification

O 1

1/80

Not Used

1271

Industry Code

O 5

1/30

Not Used

1073

Yes/No Condition or Response Code

O 1

REF*BB - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on a previously authorized health care service review and the authorization number assigned by the UMO is known and different from the number specified at the Patient Event Level (Loop 2000E). If not required by this implementation guide, do not send.

TR3 Notes:

If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.
This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱A123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*NT - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on a previous health care services review request for which the UMO has returned a response that contained an administrative reference number at the Service level for this service (Loop 2000F REF segment where REF01 = NT) and did not return a certification number in HCR02. If not required by this implementation guide, do not send.

TR3 Notes:

This is the administrative number assigned by the UMO to the original service review outcome. This is not the trace number assigned by the requester.

TR3 Example:

REF✱NT✱123Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*472 - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to those authorizations for service for a specific service date or service date range. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱D8✱20221030~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Service Date

DTP*102 - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to authorizations for a service issued on a specific date or within a specific date range that is different from the certification date(s) specified in the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱102✱D8✱20221002~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Issue Date

DTP*036 - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to authorizations for a service that expire on or by a specific date or within a specific date range and the date(s) differ from the certification expiration date(s) specified at the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱036✱D8✱20221002~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Expiration Date

DTP*007 - CERTIFICATION EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to those certifications that are effective for a specific date or date range and the effective date(s) differ from the effective date(s) specified at the Patient Event level (Loop 2000E) of this inquiry. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Effective Date

HI - ADDITIONAL SERVICE DESCRIPTION

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the requester needs to limit the inquiry to authorizations related to a specific Additional Service Description Code associated with a single episode of care. If not required by this implementation guide, do not send.

TR3 Example:

HI✱AAA:422011000124105~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE: 662: SNOMED, Systematized Nomenclature of Medicine

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

Not Used

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1-4

1251

Date Time Period

X 1

1/35

Not Used

1-5

782

Monetary Amount

O 1

1/18

Not Used

1-6

380

Quantity

O 1

1/15

Not Used

1-7

799

Version Identifier

O 1

1/30

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

Not Used

1-10

1271

Industry Code

O 1

1/30

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

Not Used

C022

Health Care Code Information

O 1

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

P0304
If either SV103 or SV104 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a specific professional service. If not required by this implementation guide, do not send.

TR3 Notes:

If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.

TR3 Example:

SV1✱HC:99211:25✱✱UN✱1~

SV1

✱

C003

✱

✱

✱

✱

✱

✱

Diagnosis
Code Pointr

✱

✱

✱

✱

✱

✱

✱

✱

✱

Healthcare
Short Code

✱

✱

✱

✱

✱

Required

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

Required

1-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Use when reporting the Device Identifier of Unique Device Identifier.

Prior to the mandated implementation date for the Unique Device Identifier, willing trading partners may agree to follow an early implementation approach.

Code Source: FDA Global Unique Device Identifier Database (GUDID) http://accessgudid.nlm.nih.gov/
Available from:
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Not Used

1-3

1339

Procedure Modifier

O 1

Not Used

1-4

1339

Procedure Modifier

O 1

Not Used

1-5

1339

Procedure Modifier

O 1

Not Used

1-6

1339

Procedure Modifier

O 1

Not Used

1-7

352

Description

O 1

1/80

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific range of procedures as specified on the original request for authorization. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

Not Used

1-9

1339

Procedure Modifier

O 1

Not Used

1-10

1339

Procedure Modifier

O 1

Not Used

1-11

1339

Procedure Modifier

O 1

Not Used

1-12

1339

Procedure Modifier

O 1

Not Used

782

Monetary Amount

O 1

1/18

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Not Used

1331

Facility Code Value

O 1

1/3

Not Used

1271

Industry Code

O 1

1/30

Not Used

1328

Diagnosis Code Pointer

O 12

1/2

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1340

Multiple Procedure Code

O 1

1/2

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1364

Review Code

O 1

1/2

Not Used

1341

National or Local Assigned Review Value

O 1

1/2

Not Used

1327

Copay Status Code

O 1

Not Used

1334

Health Care Professional Shortage Area Code

O 1

Not Used

127

Reference Identification

O 1

1/80

Not Used

116

Postal Code

O 1

3/15

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1337

Level of Care Code

O 1

Not Used

1360

Provider Agreement Code

O 1

SV2 - INSTITUTIONAL SERVICE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

R0102
At least one of SV201 or SV202 is required.
P0405
If either SV204 or SV205 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a specific Institutional Service or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

TR3 Notes:

If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.
In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV2✱120✱✱✱DA✱5~
SV2✱300✱HC:80019✱✱UN✱1~

SV2

✱

✱

✱

✱

✱

✱

✱

✱

✱

1345

Nurse Home
Status Code

✱

Situational

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEMANTIC: SV201 is the revenue code.

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when inquiring on authorizations for a specific revenue code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

Situational

C003

Composite Medical Procedure Identifier

X 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when inquiring on authorizations for a specific procedure code. If not required by this implementation guide, do not send.

Required

2-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE: 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE: 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Mutually Defined

Required

2-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Not Used

2-3

1339

Procedure Modifier

O 1

Not Used

2-4

1339

Procedure Modifier

O 1

Not Used

2-5

1339

Procedure Modifier

O 1

Not Used

2-6

1339

Procedure Modifier

O 1

Not Used

2-7

352

Description

O 1

1/80

Situational

2-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

Not Used

2-9

1339

Procedure Modifier

O 1

Not Used

2-10

1339

Procedure Modifier

O 1

Not Used

2-11

1339

Procedure Modifier

O 1

Not Used

2-12

1339

Procedure Modifier

O 1

Not Used

782

Monetary Amount

O 1

1/18

Situational

355

Unit or Basis for Measurement Code

X 1

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Unit

Situational

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

Not Used

1371

Unit Rate

O 1

1/10

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1345

Nursing Home Residential Status Code

O 1

Not Used

1337

Level of Care Code

O 1

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a specific Dental Service. If not required by this implementation guide, do not send.

TR3 Notes:

If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.

TR3 Example:

SV3✱AD:D2150✱✱✱✱✱1~

SV3

✱

C003

✱

✱

✱

Oral Cavity
Designat.

✱

1358

Prosthesis/
Inlay Code

✱

✱

✱

✱

✱

✱

1328

Diagnosis
Code Pointr

O 12

Required

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

Required

1-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE: 135: American Dental Association

Required

1-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

Not Used

1-3

1339

Procedure Modifier

O 1

Not Used

1-4

1339

Procedure Modifier

O 1

Not Used

1-5

1339

Procedure Modifier

O 1

Not Used

1-6

1339

Procedure Modifier

O 1

Not Used

1-7

352

Description

O 1

1/80

Situational

1-8

234

Product/Service ID

O 1

1/80

Identifying number for a product or service

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific range of dental procedures as specified on the original request for authorization. If not required by this implementation guide, do not send.

INDUSTRY NAME: Product or Service ID

Use SV301-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

Not Used

1-9

1339

Procedure Modifier

O 1

Not Used

1-10

1339

Procedure Modifier

O 1

Not Used

1-11

1339

Procedure Modifier

O 1

Not Used

1-12

1339

Procedure Modifier

O 1

Not Used

782

Monetary Amount

O 1

1/18

Not Used

1331

Facility Code Value

O 1

1/3

Situational

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for treatment of an area of the oral cavity. If not required by this implementation guide, do not send.

Do not use this element for inquiring on authorizations for individual teeth. Use the Tooth Information (TOO) segment in this loop to inquire on individual teeth.
The oral cavity area codes are contained in the ISO TC 106 Designation System for Teeth and Areas of the Oral Cavity.

Required

4-1

1361

Oral Cavity Designation Code

M 1

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

Not Used

4-2

1361

Oral Cavity Designation Code

O 1

1/3

Not Used

4-3

1361

Oral Cavity Designation Code

O 1

1/3

Not Used

4-4

1361

Oral Cavity Designation Code

O 1

1/3

Not Used

4-5

1361

Oral Cavity Designation Code

O 1

1/3

Situational

1358

Prosthesis, Crown or Inlay Code

O 1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for prosthesis, crown, or inlay with the status indicated. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the procedure specified.

INDUSTRY NAME: Service Unit Count

Number of procedures

Not Used

352

Description

O 1

1/80

Not Used

1327

Copay Status Code

O 1

Not Used

1360

Provider Agreement Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1328

Diagnosis Code Pointer

O 12

1/2

TOO*JP - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

P0102
If either TOO01 or TOO02 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a specific tooth number and/or tooth surface related to this procedure line. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~

TOO

✱

✱

✱

Required

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

Required

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Code source 135: American Dental Association Codes

Situational

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when limiting the inquiry to a tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

Required

3-1

1369

Tooth Surface Code

M 1

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

Not Used

3-2

1369

Tooth Surface Code

O 1

1/2

Not Used

3-3

1369

Tooth Surface Code

O 1

1/2

Not Used

3-4

1369

Tooth Surface Code

O 1

1/2

Not Used

3-5

1369

Tooth Surface Code

O 1

1/2

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

P0405
If either DN204 or DN205 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when SV3 is valued and inquiring on authorizations for which a missing tooth, extracted tooth, tooth to be extracted, or impacted tooth is related to this service. If not required by this implementation guide, do not send.

TR3 Example:

DN2✱5✱E✱✱✱✱JP~

DN2

✱

✱

✱

✱

✱

✱

Required

127

Reference Identification

M 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: DN201 is the tooth number.

INDUSTRY NAME: Tooth Number

The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Required

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

CODE

DEFINITION

To Be Extracted

Impacted

Missing

Extracted

Not Used

380

Quantity

O 1

1/15

Not Used

1250

Date Time Period Format Qualifier

X 1

2/3

Not Used

1251

Date Time Period

X 1

1/35

Required

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

SEMANTIC: DN206 designates the code set used to identify the tooth in DN201.

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE: 135: American Dental Association

DRA - DRUG AUTHORIZATION

X12 Name:

Drug Authorization

X12 Purpose:

To specify a drug for which authorization is being requested

X12 Syntax:

P0405
If either DRA04 or DRA05 is present, then the other is required.
P080910
If either DRA08, DRA09 or DRA10 are present, then the others are required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a drug name, drug therapy type or a specific drug. If not required by this implementation guide, do not send.

TR3 Notes:

If the request is for a compound drug, repeat the segment for each ingredient in the compound.

TR3 Example:

DRA✱INFLIXIMAB 10 MG✱I✱N4:57894003001✱UN✱20✱INFUSE OVER AT LEAST 2 HOURS. BEGIN AT 40 ML/HR FOR 15 MINUTES, THEN INCREASE RATE TO 80 ML/HR FOR 30 MINUTES. IF TOLERATED INCREASE TO 160 ML/HR FOR THE DURATION OF INFUSION✱N✱N✱✱✱✱✱✱43~

DRA

✱

✱

Certificate
Type Code

✱

C003

✱

✱

✱

Free-Form
Message Txt

1/264

✱

✱

✱

✱

✱

Free-Form
Message Txt

✱

✱

✱

✱

Free-Form
Message Txt

O 999

1/264

Required

352

Description

M 2

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: DRA01 is the drug name. Position of data in the repeating data element conveys no significance.

INDUSTRY NAME: Drug Name

Required

1322

Certification Type Code

O 1

Code indicating the type of certification

SEMANTIC: DRA02 is the drug therapy type.

INDUSTRY NAME: Drug Therapy Type

CODE

DEFINITION

Extension

Use when this is the extension of the first use of this drug or its therapeutic equivalent as a supplemental therapy for treatment of this condition.

Initial

Use when this is the first use of this drug or its therapeutic equivalent for treatment of this condition.

Renewal

Use when this is for continuation of the use of this drug or its therapeutic equivalent for treatment of this condition.

Revised

Use when this is the first use of this drug or its therapeutic equivalent to replace a previous unsuccessful or non-optimal therapy for treatment of this condition.

Situational

C003

Composite Medical Procedure Identifier

O 2

To identify a medical procedure by its standardized codes and applicable modifiers

SEMANTIC: DRA03 Position of data in the repeating data element conveys no significance.

X12 COMPOSITE SEMANTIC NOTES:

C003-01 qualifies C003-02 and C003-08.
If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
C003-03 modifies the value in C003-02 and C003-08.
C003-04 modifies the value in C003-02 and C003-08.
C003-05 modifies the value in C003-02 and C003-08.
C003-06 modifies the value in C003-02 and C003-08.
C003-07 is the description of the procedure identified in C003-02.
C003-08 represents the ending value in the range in which the code occurs.
C003-09 modifies the value in C003-02 and C003-08.
C003-10 modifies the value in C003-02 and C003-08.
C003-11 modifies the value in C003-02 and C003-08.
C003-12 modifies the value in C003-02 and C003-08.

SITUATIONAL RULE: Required when inquiring on authorizations for a specific drug. If not required by this implementation guide, do not send.

Required

3-1

235

Product/Service ID Qualifier

M 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

National Drug Code in 5-4-2 Format

CODE SOURCE: 240: National Drug Code by Format

Required

3-2

234

Product/Service ID

M 1

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Not Used

3-3

1339

Procedure Modifier

O 1

Not Used

3-4

1339

Procedure Modifier

O 1

Not Used

3-5

1339

Procedure Modifier

O 1

Not Used

3-6

1339

Procedure Modifier

O 1

Not Used

3-7

352

Description

O 1

1/80

Not Used

3-8

234

Product/Service ID

O 1

1/80

Not Used

3-9

1339

Procedure Modifier

O 1

Not Used

3-10

1339

Procedure Modifier

O 1

Not Used

3-11

1339

Procedure Modifier

O 1

Not Used

3-12

1339

Procedure Modifier

O 1

Not Used

355

Unit or Basis for Measurement Code

X 1

Not Used

380

Quantity

X 1

1/15

Not Used

933

Free-form Message Text

O 1

1/264

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1073

Yes/No Condition or Response Code

X 1

Not Used

374

Date/Time Qualifier

X 1

Not Used

373

Date

X 1

Not Used

933

Free-form Message Text

O 999

1/264

Not Used

380

Quantity

O 1

1/15

Not Used

C060

Question and Answer

O 999

Not Used

1330

Dosage Form Code

O 1

Not Used

933

Free-form Message Text

O 999

1/264

NM1 - SERVICE PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when inquiring on authorizations for a specific service provider, specialist, or specialty entity for this service that is different from the provider, specialist, or specialty entity identified in Loop 2010E (Patient Event Provider Name). If not required by this implementation guide, do not send.

TR3 Notes:

This segment is required if Loop 2010F is used.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Operating Physician

Other Physician

Service Location

Admitting Physician

Assistant Surgeon

Ordering Physician

Supervising Physician

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Service Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Middle Name or Initial

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the suffix is needed to further identify the Service Provider: e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Service Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

REF - SERVICE PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:

Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when the service provider has not been assigned an NPI and the UMO identified in loop 2010AA or 2010AB has assigned its own identifier for this provider.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Service Provider Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

352

Description

X 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See Code Source 22: State and Outlying Areas of the US.

Not Used

C040

Reference Identifier

O 1

N3 - SERVICE PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when limiting the inquiry to authorizations for services at a specific provider location and the service provider has multiple locations. If not required by this implementation guide, do not send.

TR3 Example:

N3✱123 MAIN STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Service Provider Address Line

Use this element for the first line of the provider's address.

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Address Line

N4 - SERVICE PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Postal Code
Formatted

X 1

3/20

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Service Provider City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Service Provider Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Provider Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Service Provider Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PRV - SERVICE PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

SE - TRANSACTION SET TRAILER

X12 Name:

Transaction Set Trailer

X12 Purpose:

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

X12 Comments:

SE is the last segment of each transaction set.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

SE✱24✱0002~

✱

✱

Required

Number of Included Segments

M 1

1/10

Total number of segments included in a transaction set including ST and SE segments

INDUSTRY NAME: Transaction Segment Count

Required

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

The Transaction Set Control Number in ST02 and SE02 must be identical.

GE - FUNCTIONAL GROUP TRAILER

X12 Name:

Functional Group Trailer

X12 Purpose:

To indicate the end of a functional group and to provide control information

X12 Comments:

The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GE✱1✱1~

✱

Number of
TS Included

✱

Required

Number of Transaction Sets Included

M 1

1/6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

Required

Group Control Number

M 1

1/9

Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.

IEA - INTERCHANGE CONTROL TRAILER

X12 Name:

Interchange Control Trailer

X12 Purpose:

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Segment Usage:

Required

Segment Repeat:

TR3 Example:

IEA✱1✱000000905~

IEA

✱

I16

Num of Incl
Funct Group

✱

Required

I16

Number of Included Functional Groups

M 1

1/5

A count of the number of functional groups included in an interchange

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Value in IEA02 must be identical to the value in ISA13.

278 Health Care Services Review - Inquiry and Response (008020X327)

JANUARY 2022

Copyright © 2008-22, X12 Incorporated, Format © 2008-22 Washington Publishing Company. Exclusively published by the Washington Publishing Company. No part of this publication may be distributed, posted, reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner.

Abstract

The Health Care Services Review Inquiry and Response Implementation Guide describes the use of the X12 Health Care Services Review Information (278) transaction set for the following business usages:

Make inquiries to utilization management organizations for information on previously processed health care services
Send response(s) to inquiry(ies) on previously processed health care services

Preface

X12 standards are developed to identify the broadest data requirements for a transaction set. Type 3 Technical Reports (TR3), also known as implementation guides, define the explicit data requirements for a specific business purpose. Trading partners who implement according to the instructions in this TR3 can exchange data consistently with multiple trading partners.

As X12 does not define transport requirements, trading partners define their specific transport requirements separately.

1.1 Implementation Purpose and Scope

For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

The purpose of this implementation guide is to provide standardized data requirements and content for all users who inquire on authorizations or certifications or who respond to such inquiries using the X12, Health Care Services Review Information (278). This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for electronic health care service review inquiries and responses. The intention of the developers of the 278 is represented in this guide.

This implementation guide is designed to assist providers who inquire about certification decisions (specialty care, treatment, admission) and the Utilization Management Organizations (UMO) who respond to those inquiries using the 278 format. In the context of this implementation guide, an inquiry refers to a transaction that asks for information on previously processed requests for authorization or certification.

1.2 Version Information

This implementation guide is based on the October 2020 X12 standards, referred to as Version 8, Release 2 (008020).

The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 008020X327.

The two-character Functional Identifier Code for the transaction set included in this implementation guide:

HI Health Care Services Review Information (278)

The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be transmitted in the Functional Group Header (GS segment) that begins a functional group of these transaction sets. For more information, see the descriptions of GS01 and GS08 in Appendix C EDI Control Directory.

1.3.1 Batch and Real-Time Usage

There are multiple methods available for sending and receiving business transactions electronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery or transmits the response transaction back to the sender of the original transaction. The sender of the original transmission reconnects at a later time and picks up the response transaction. Note: The sender of the original transmission may not always be the entity that picks up the response transaction at a later time (e.g. Provider submitting through a clearinghouse.)

Real-Time - In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. This implementation guide does not set specific response time parameters for implementers.

This implementation guide was based on requirements for batch mode. Willing trading partners may use batch or real-time mode.

1.3.2 Other Usage Limitations

Real-Time Delivery of the 278
This implementation guide requires the use of a separate 278 inquiry transaction (ST to SE) for each real-time patient event inquiry or global inquiry as defined in Section 1.4.2 - Business Events Supported in this Guide - Inquiry and Response.

If the UMO system cannot process the 278 inquiry transaction upon receipt, the UMO system must return a 278 inquiry response transaction to indicate the reason for rejecting the transaction.

Batch Delivery of the 278
In batch mode, the 278 inquiry transaction can include one or more patient event or global inquiries from the requester to the UMO. This implementation guide requires that the batch 278 inquiry transaction include no more than 99 patient event inquiries or 5 global inquiries per 278 inquiry transaction (ST to SE).

1.4 Business Usage

The 278 has the flexibility to accommodate the exchange of information between providers and review entities. This section introduces the business events and processes associated with the 278.

1.4.1 Health Care Transaction Flow

Each X12 implementation guide explains how to use X12 transaction sets to meet a single defined business purpose. The diagrams found at https://www.x12.org/flow depict the business functions supported by the X12 health care implementation guides.

1.4.2 Business Events Supported in this Guide - Inquiry and Response

The 278 Health Care Services Review - Inquiry and Response handles informational inquiries and their related responses. It enables a participant to inquire about existing certifications and authorizations. As illustrated in Figure 1.1 - Health Care Services Review - Inquiry and Response, the primary participants are providers and UMOs where the entity inquiring is either the primary provider or the service provider.

Figure 1.1 - Health Care Services Review - Inquiry and Response

Health Care Services Review - Inquiry and Response

The following are examples of business events supported by this implementation. These events are all examples of inquiries to obtain complete referral or certification information for 278 service review requests previously processed.

Specialty Care Referral Inquiry
A specialist has not received a referral for a patient who has arrived for an appointment. The specialist sends a 278 inquiry to the UMO to verify that an approved referral exists for this patient. The UMO uses the 278 to transmit an inquiry response, listing one or more previous referral review decisions, back to the requesting provider. The health care provider can also use this inquiry when a patient is scheduled to arrive and the referral authorization information is not available.

Admission Certification Inquiry
A patient arrives or is scheduled to arrive for a hospital admission, and the pre-admission certification information previously requested from the UMO by the primary care provider (PCP) is not available. The provider uses the 278 inquiry to verify that the patient's primary care provider received certification for the admission. The UMO uses the 278 inquiry response to transmit any available admission certification information to the requesting provider.

Health Care Service Certification Inquiries
A patient is scheduled to receive a series of services or supplies; for example physical therapy and equipment for home exercises. The physical therapist has no certification information available and uses the 278 inquiry to verify that the services previously requested from the UMO by the PCP or specialist are authorized. The UMO returns the appropriate certification information in the 278 inquiry response.

All Patient Certifications Inquiry
The 278 inquiry enables the requester to determine the range of review activity associated with a specific patient to be included on the response. Some examples follow.

A provider inquires on all certifications (within a date range) for one patient from a UMO. This implementation would typically be used when a PCP wants to see all review activity (within a date range) with a UMO for one of his patients.
A provider (such as a hospital, clinic, group practice, or physician) can inquire on all certifications from a UMO where the current requesting provider was the original requesting provider for a specific patient. If the inquiry does not specify a date range, the UMO might limit the number of certifications that qualify for inclusion in the response. For example, the UMO might limit the response to the five most recent certifications.
A provider inquires on all review activities (referrals and certifications) from a UMO where the current requesting provider is the patient event provider or service provider for a specific patient. Based on the review entity's rules, the provider may have authority to view only some of that activity.

NOTE
Implementers of the 278 Inquiry and Response must establish response content criteria based on the identity of the requesting entity. For example, UMOs might limit the response to a specialist to those services that pertain to the specialist's treatment of the patient only and not return any additional authorization information associated with the patient event.

Multiple Patients Certification Inquiry
The 278 inquiry provides limited support for inquiring on multiple certifications for multiple patients. In this type of inquiry, the requester uses a single transaction to inquire on the status of authorizations for more than one patient. Three scenarios illustrating the use of the multiple patients inquiry follow.

A number of patients are scheduled for appointments with a specialist on a specific day. The specialist's office needs to determine if these patients have authorizations from the UMO for the specialist visit. The specialist's office submits a batch inquiry transaction, listing each of the patients scheduled. The inquiry must include the appropriate member ID information for each patient and the inquiring provider must be associated to the members' event history on the inquiry. Additional information, such as the service(s) to be performed, may help to limit the number of patient event authorizations returned per patient on the response.
A provider has submitted service review requests for several patients for which he has not received final responses. The provider inquires on the status of these requests. The provider submits a batch inquiry transaction listing each patient for which he has not received a final services review response. The inquiry must include the appropriate member ID information for each patient and the inquiring provider must be associated to the members' event history on the inquiry. Additional information, such as the date of the original request, may help to limit the number of patient event authorizations returned per patient on the response.
A primary care provider (PCP) has several patients for whom he tracks all authorizations initiated by himself or by specialists. The PCP inquires to determine if the UMO has authorized any service reviews for these patients. The provider submits a batch inquiry transaction listing each of the patients and can specify a certification effective date or issue date for each, if applicable. The inquiry must include the appropriate member ID information for each patient. Additional information, such as the patient diagnosis or service(s) to be performed, may help to limit the number of patient event authorizations returned per patient on the response.

Global Inquiry
The 278 inquiry also enables the requester to inquire on the status of authorizations that meet specific patient event or service criteria without identifying a specific patient. Inquiries of this type are denoted in the transaction with a BHT02 value of 51 (Historical Inquiry). A scenario illustrating the use of a global inquiry follows.

A provider has submitted service review requests for several patients for which he has not received final responses. The inquiry does not specify the name or member information for each patient. Instead, the provider inquires on the status of all the requests submitted on a specific date. The inquiry transaction identifies the inquiring provider as the referring provider and specifies the date when these initial service review requests were initiated.

1.4.3 Business Events Supported in Other 278 Guides

The 278 transaction set accommodates additional health care services review business events that are covered in separate 278 implementation guides. A brief description of these business events follows.

1.4.3.1 Notification

Trading partners can use the 278 transaction set to share unsolicited information with providers, payers, delegated UMO entities and/or other providers. This information may include health service reviews or notification of scheduled treatment, or the beginning and end of treatment. A participant who is the recipient of the information may acknowledge they received the data, or reject the data due to specific application layer processing, but may not respond with any review decision outcome.

This implementation guide supports the following categories of notifications.

Advance Notification for:

scheduled inpatient admissions
scheduled health services events
scheduled specialty care services

Completion Notification for:

patient arrival at a facility
patient discharge from a facility
services completion notice for any specific episode of care

Information Copy for any Health Services Review information sent to primary provider(s), service provider(s), or other Health Care entities requiring the information for specific purposes.

Change Notification for reporting changes to the detail of a previously sent notification or information copy.

As illustrated in Figure 1.2 - Health Care Services Review - Notification, unsolicited information is sent from the information source to both the UMO and Service Provider. For example, in a situation where the primary care provider may authorize specialty referrals that do not require review for medical necessity, appropriateness, or level of care, the primary care provider is the information source. This provider might have responsibility for notifying both the UMO and the service provider of the specialty referral, without the expectation of a response.

Figure 1.2 - Health Care Services Review - Notification

Health Care Services Review - Notification

1.4.3.2 Request and Response

Health Care Services Review - Request and Response includes the following business events.

admission certification review request and associated response
referral review request and associated response
health care services certification review request and associated response
extend certification review request and associated response
certification appeal review request and associated response
reservation of medical services request and associated response
cancellations of service reservations request and associated response

As illustrated in Figure 1.3 - Health Care Services Review - Request for Review and Response, the exchange of information is between the primary parties, the provider and the UMO.

Figure 1.3 - Health Care Services Review - Request for Review and Response

Health Care Services Review - Request for Review and Response

1.5 Business Terminology

To ensure consistent use of terms, definitions, and acronyms across X12 products, X12 maintains the Wordbook, a comprehensive corporate glossary. The included terms are either proprietary to X12, cite definitions published by another authority, or represent common terms and definitions that are relevant to X12's work. The terms and definitions defined in the Wordbook are used in X12 work products when applicable, without modification or revision. The Wordbook can be referenced online at wordbook.x12.org.

1.6 Transaction Acknowledgments

The purpose of transaction acknowledgments is to report to the sender whether the transaction being acknowledged was accepted or rejected.

The X12 Technical Report Type 2, Acknowledgment Reference Model provides guidance on several control structures and transaction set standards intended to augment EDI auditing and control systems.

1.7 Related Transactions

There are no transactions related to the transactions described in this implementation guide.

1.8 Trading Partner Agreements

Trading partner agreements are used to establish and document the relationship between trading partners. A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide.

1.9 Transaction Compliance

There are three types of compliance that may be relevant to a transmitted transaction.

Compliance with implementation guide requirements

Compliance with state and federal regulation

Compliance with trading partner contractual agreements

1.9.1 Transaction Compliance with Implementation Guide Requirements

A transaction complies with X12 implementation guide requirements if the transaction satisfies all format and content rules and constraints specified in the applicable X12 standards and the implementation guide (also known as a TR3) itself.

Should additional clarification of an X12 implementation guide requirement be desired, two options are available.

The following X12 work products can be viewed online at https://products.x12.org:
Interchange Control Structure (X12.5)
Application Control Structure (X12.6)
Interconnect Mailbag Control Structures (X12.56)
Security Structures (X12.58)
Implementation of EDI Structures - Semantic Impact (X12.59)
Design Rules and Guidelines (X12.61)
Acknowledgment Reference Model
Reference Model for Inclusion of Sender and Receiver Identification in XML
Compliance in X12.
The X12 Request for Interpretation (RFI) viewer may be searched: https://rfi.x12.org. If existing RFI responses do not clarify the outstanding issue, a new RFI may be submitted.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that are not TR3-compliant based on its own business process.

A receiver may specify its business rules in a trading partner agreement or companion document. As stated in §1.8, these documents do not override TR3 requirements, nor change how transaction compliance with this TR3 is determined.

1.9.2 Transaction Compliance with State and Federal Regulations

This implementation guide has been developed for use as an insurance industry implementation guide. At the time of publication it has not been adopted as a state or federal standard. Should this implementation guide be adopted as a standard, the adopting authority will establish compliance dates for its use by impacted entities.

X12 is not the authority for determining compliance with regulatory requirements that might further constrain implementation guide requirements. Questions of compliance for regulatory requirements should be directed to the governing authority.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with applicable regulatory requirements as specified by the applicable regulation(s) or governing authority.

1.9.3 Transaction Compliance with Contractual Requirements

X12 is not the authority for determining compliance with contractual requirements that might further constrain implementation guide requirements. Questions of compliance for contractual requirements should be directed to the contracting entity.

X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with contractual requirements as specified by the applicable contract or contracting entity.

1.10 Data Overview

Interested parties can exchange the 278 transaction in a bi-directional re-quest/response mode of operation. In this implementation, a participant inquires on the status of authorizations and a review entity responds to that request. This section provides general information on the structure of the transaction set as represented in this implementation guide.

NOTE
See Appendix B, X12 Control and Guidance, to review the transaction set structure, including descriptions of segments, data elements, levels, and loops.

1.10.1 Overall Data Architecture

The 278 is divided into two levels, or tables. Refer to Section 2, Transaction Set, for a description of the format presented.

The Header level, Table 1, contains the purpose code for the transaction set as well as date and time stamps. The value assigned to BHT02 in the header provides additional information about the business purpose of the transaction. A BHT02 value of 28 (Query) indicates an inquiry for authorizations for the patient(s) identified and a BHT02 value of 51 (Historical Inquiry) identifies a global inquiry for all authorizations on file that match the search criteria specified where that search criteria does not identify any specific patients.

A BHT02 value of 49 (Original - No Response Necessary) indicates a response to a patient inquiry and a value of 52 (Response to Historical Inquiry) indicates a response to a global inquiry.

This implementation uses the BHT06 to further qualify the business purpose of the transaction. BHT06, used in conjunction with BHT02, enables the trading partners to specify the amount of detail to exchange in global inquiries. A BHT06 value of RD (Returns Detail) on the inquiry indicates that the requester (or requesting system) can handle a response containing the full detail for the available records on the UMO system. A BHT06 value of ZW (Sort and Segregate Detail) indicates that the requester (or requesting system) prefers summary detail for the available records on the UMO system. The requester can use this, in combination with a global inquiry (BHT02 = 51), to indicate a preference for summary responses. This implementation guide does not require that UMO systems support the ability to return both summary and detail responses.

On the response, BHT06 provides information on the status of the response to the inquiry. A value of RD (Returns Detail) advises that the response contains detail information and a value of ZW advises that the response contains only summary information on the authorizations available in the UMO system. Depending on the detail provided on the inquiry, the UMO system may have a large number of records on file that match the query criteria. Some UMO systems have limitations on the number of authorizations returned per inquiry. The UMO system can use a response BHT06 value of RS (Response - Additional Responses Available) to indicate that more records qualified than the UMO system returned on the response.

Refer to Section 1.11.5 - Summary Responses and Detail Responses for guidelines on the content of these responses.

The Detail level, Table 2, contains all the data relating to the transaction, including transaction participants, the patient, all providers, and services detail information. Table 2 uses a hierarchical data structure. For the types of business transactions that this implementation guide addresses, the following HL levels apply to both the inquiry and the response.

Loop 2000A contains the UMO
Loop 2000B contains the Requester
Loop 2000C contains the Subscriber
Loop 2000D contains the Dependent
Loop 2000E contains the Patient Event and Patient Event Providers
Loop 2000F contains the Service and Service Providers

One Patient Per Transaction
The 278 supports multiple types of service review inquiries. The number of referrals and certifications that qualify for inclusion in the response will vary based on the criteria specified on the inquiry and the review entity's rules for relinquishing patient information to the requesting provider. An inquiry respecting a single patient can result in a response that contains multiple patient event loops, one for each patient event authorized. Each of these loops may contain one to many service loops depending on the complexity of services authorized. Due to the multiplicity of uses of the 278, this guide requires a separate transaction for each patient inquiry submitted in real-time mode.

Refer to "Multiple Patients Certification Inquiry" in Section 1.4.2 - Business Events Supported in this Guide - Inquiry and Response for scenarios that support multiple patients on the inquiry.

Service Review Participants
This implementation uses a separate hierarchical level to identify each participant in the service review. Loop 2000A and Loop 2000B represent the UMO (reviewer or information source) and requesting provider respectively. Loop 2000C and Loop 2000D represent the subscriber and dependent. If the subscriber is the patient or if the patient has a unique identification number, only Loop 2000C is required. Loop 2000E carries information about the patient event and the provider(s) (referred-to providers) associated with this patient event. Loop 2000F carries information about specific services and the service provider(s) for those individual services.

Patient Event
Patient event in this guide refers to the service or group of services associated with a single episode of care. The 278 supports multiple types of service review requests. Due to the multiplicity of uses of the 278, this guide requires that inquiries submitted in real-time mode use separate transaction sets for different patients and events. This is a one-to-one style relationship: one transaction set for one patient event. Loop 2000E contains the information associated with the patient event. This includes the diagnosis and condition of the patient, the identification of the category of services associated with this patient event, and the provider (facility or specialist) that will provide the services associated with this patient event.

Services
A health care services review can include a request to authorize a specific service and service provider associated with that service. Loop 2000F identifies the specific services included in this patient event and the providers that will deliver these services.

NOTE
The inclusion of detailed service review information on the inquiry limits the authorizations that qualify for inclusion on the response.

1.10.2 Sample Table 2 Configurations

The following are sample Table 2 configurations.

The following example represents an inquiry for authorizations for a specific patient event, such as ambulance transport, for a dependent of a subscriber.

UMO (Loop 2000A)

Requester (Loop 2000B)

Subscriber (Loop 2000C)

Dependent (Loop 2000D)

Patient Event (Loop 2000E)

The following example represents a response to an inquiry for a category of service, such as ambulance transport, for a dependent of a subscriber.

UMO (Loop 2000A)

Requester (Loop 2000B)

Subscriber (Loop 2000C)

Dependent (Loop 2000D)

Patient Event (Loop 2000E)

The following example represents an inquiry from a PCP to a UMO on all certifications for a patient who is the Subscriber.

UMO (Loop 2000A)

Requester (Loop 2000B) - PCP

Subscriber (Loop 2000C) - Patient

Patient Event (Loop 2000E) (Certification Search Criteria)

The following example represents a response (from a UMO to a PCP) to an inquiry on all authorizations (certifications) for a patient who is the Subscriber. The UMO system contains two certifications that match the query criteria.

UMO (Loop 2000A)

Requester (Loop 2000B) - PCP

Subscriber (Loop 2000C) - Patient

Patient Event (Loop 2000E)

Service (Loop 2000F) - Authorization 1

Patient Event (Loop 2000E)

Service (Loop 2000F) - Authorization 2

In the preceding example, the second patient event level is for a different episode of care and associated authorization.

NOTE
The providers, including the original referring or ordering provider, associated with the patient event or specific service are identified within the patient event and service loops respectively.

1.10.3 Intended Segment Use

Each hierarchical level (loop) in this implementation consists of multiple segments and is based on the same standard hierarchical structure of segments. An implementation specifies the maximum segments you can include, per hierarchical level, to describe the service review participants, patient event, and services.

Inquiry
For an inquiry transaction, Table 1.1 - Intended Segment Use for an Inquiry Transaction, identifies the intended segment use by hierarchical level.

Table 1.1 - Intended Segment Use for an Inquiry Transaction

Segment Position	Segment ID	UMO HL	Requester HL	Subscriber HL	Dependent HL	Patient Event HL	Service HL
0100	HL	YES	YES	YES	YES	YES	YES
0200	TRN			YES	YES	YES	YES
0300	AAA
0400	UM					YES	YES
0500	HCR					YES	YES
0600	REF					YES	YES
0700	DTP					YES	YES
0800	HI					YES
0810	SV1						YES
0820	SV2						YES
0830	SV3						YES
0840	TOO						YES
0900	HSD
1000	CRC
1100	CL1
1200	CR1
1300	CR2
1400	CR5
1500	CR6
1520	CR7
1530	CR8
1550	PWK
1600	MSG
1700	NM1	YES	YES	YES	YES	YES	YES
1800	REF		YES	YES	YES	YES	YES
1900	N2
2000	N3		YES			YES	YES
2100	N4		YES			YES	YES
2200	PER		YES
2300	AAA
2400	PRV		YES			YES	YES
2500	DMG			YES	YES
2600	INS
2700	DTP

Response
Table 1.2 - Intended Segment Use for an Inquiry Response Transaction, identifies the intended segment use by hierarchical level for an inquiry response transaction.

Table 1.2 - Intended Segment Use for an Inquiry Response Transaction

Segment Position	Segment ID	UMO HL	Requester HL	Subscriber HL	Dependent HL	Patient Event HL	Service HL
0100	HL	YES	YES	YES	YES	YES	YES
0200	TRN			YES	YES	YES	YES
0300	AAA	YES				YES	YES
0400	UM					YES	YES
0500	HCR					YES	YES
0600	REF					YES	YES
0700	DTP					YES	YES
0800	HI					YES
0810	SV1						YES
0820	SV2						YES
0830	SV3						YES
0840	TOO						YES
0900	HSD					YES	YES
1000	CRC
1100	CL1					YES
1200	CR1					YES
1300	CR2					YES
1400	CR5					YES
1500	CR6					YES
1520	CR7
1530	CR8
1550	PWK
1600	MSG					YES	YES
1700	NM1	YES	YES	YES	YES	YES	YES
1800	REF		YES	YES	YES	YES	YES
1900	N2
2000	N3			YES	YES	YES	YES
2100	N4			YES	YES	YES	YES
2200	PER	YES				YES	YES
2300	AAA	YES	YES	YES	YES	YES	YES
2400	PRV		YES			YES	YES
2500	DMG			YES	YES
2600	INS
2700	DTP

1.10.4 Matching the Inquiry with Its Response

This implementation guide provides several methods to enable requesters, clearinghouses, and UMOs to trace the transaction or match the response to the inquiry. This section describes the segments and data elements that carry these identifiers.

BHT03 - Submitter Transaction Identifier
BHT03 identifies the transaction at its highest level. This is particularly useful in reconciling 278 rejection response transactions that may not contain all of the HL Loops. BHT03 is required on both the inquiry and the response. When the 278 inquiry and response are used in real-time mode, the receiver of the 278 inquiry (whether it is a clearinghouse or UMO) must return the inquiry BHT03 value in the 278 response BHT03.

In batch processing the responding system might not address each patient inquiry in the same batch response. Therefore, this implementation guide does not require the receiver of the request transaction to return the inquiry BHT03 value on the batch response. The responder can assign its own identifier to the transaction in BHT03.

TRN Segment
The TRN is supplied solely for the convenience of the organization that originated it. It enables the originator to assign a unique ID to each unique service review inquiry and identifies the organization that generated the inquiry. Both the requester (provider) and the clearinghouse can add a TRN segment to the inquiry. Each trace number provided in a TRN segment on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.

Loop 2000E (Patient Event level)and Loop 2000F (Service level) also contain a TRN segment. Use the 2000F and/or the 2000E TRN segment in lieu of the patient level TRN only when inquiring on certifications for more than one patient event (multiple patient event loops) or service (multiple service loops) for the same patient, or when submitting a global inquiry.

Requester TRN
The requester (provider) can use this TRN segment to meet several needs. This enables the requester to accomplish the following:

uniquely identify this service review inquiry or each query contained in the inquiry within the provider's environment
match the associated response to the inquiry
facilitate routing of this response in a large health care environment. For example, it might be necessary for the requester to identify the department within the provider environment that originated the transaction.

Clearinghouse TRN
If the transaction is routed through a clearinghouse, the clearinghouse can provide its own trace number in a separate TRN segment in Loop 2000E (Patient Event), or Loop 2000F (Service) on the request to use for transaction tracking and matching purposes.

If the 278 inquiry transaction passes through more than one clearinghouse, the second (and subsequent) clearinghouse may choose one of the following options:

If the second or subsequent clearinghouse needs to assign their own TRN segment they may replace the received TRN segment belonging to the sending clearinghouse with their own TRN segment. Upon returning a 278 response to the sending clearinghouse, they must remove their TRN segment and replace it with the sending clearinghouse's TRN segment.
If the second or subsequent clearinghouse does not need to assign their own TRN segment, they must pass all TRN segments received in the 278 request back in the 278 response transaction. If the 278 request passes through a clearinghouse that adds their own TRN in addition to a requester TRN, the clearinghouse will receive a response from the UMO containing two TRN segments that contain the value "2" (Referenced Transaction Trace Number) in TRN01. If the UMO has assigned a TRN, the UMO's TRN will contain the value "1" (Current Transaction Trace Number) in TRN01. If the clearinghouse chooses to pass their own TRN values to the requester, the clearinghouse must change the value in their TRN01 to "1" because, from the requester's perspective, this is not a referenced transaction trace number.

UMO TRN
If the TRN segment is used on the inquiry, the UMO must return the trace information supplied with the request transaction in the response transaction.

UMOs can add a trace number in their own TRN segment in the same loop on the response. The UMO cannot use this trace number to identify the certification to the requester.

1.10.5 Inquiry Responses

The UMO must respond to each 278 transaction set received. If the UMO can process the 278 inquiry, the UMO must return a 278 response that contains either the authorization(s) found or the reason why no authorizations were found.

Patient Confidentiality
Inquiry responses may include authorizations that contain information concerning the patient's current condition and treatment. Implementers of the 278 inquiry and response must ensure that only authorized participants have access to this data. The UMO/responding entity should establish response content criteria based on the identity of the requesting entity. For example, UMOs might use the requesting provider's role in the care of the patient as criteria for determining what authorization information to return on the response. If the provider initiating the inquiry is the member's PCP, the UMO rules may permit the PCP to view all authorizations for that patient, regardless of what provider initiated the original service review request. These criteria must prevent the UMO's system from disseminating confidential patient information to providers not directly involved in the care of the patient.

Rejected Transactions
Missing or incorrect application data on the 278 inquiry can cause the UMO to reject the transaction. For these requests, the UMO must return a 278 inquiry response transaction that contains a AAA Request Validation segment at the appropriate level to indicate why the UMO rejected the transaction. The AAA segments in Loop 2000A (UMO) enable both the clearinghouse and the reviewer to indicate when system availability issues prohibit routing of the inquiry request for processing.

1.11 Data Use By Business Use

The segments referenced in Table 1.1 - Intended Segment Use for an Inquiry Transaction and Table 1.2 - Intended Segment Use for an Inquiry Response Transaction carry the data content of the health care services review. This section provides examples of the segments and data element values used in the hierarchical levels. The use of UMO, requester, subscriber, dependent, patient event, and service is consistent across types of health care services reviews. However, the use of the patient event and service levels differ across types of health care services reviews. Therefore, the patient event level and service level discussions in this section contain multiple examples.

Minimum Data Requirements
Factors such as the type of health care services review requested, the condition of the patient, and the individual UMO's rules for processing authorization inquiries make it difficult to identify a single set of data elements that are required for all types of inquiries. To meet the divergent needs of the UMOs and requesters, this guide includes many data elements and segments marked "situational".

NOTE
This section provides examples of types of health care service reviews and the minimum data required. Refer to Section 2 of this guide for detailed information on valuing specific data elements within the segments.

1.11.1 Transaction Participants (Loop 2000A, Loop 2000B)

The Loop 2000A and Loop 2000B hierarchical levels convey information about the primary participants in a health care service review transaction, the information source (UMO) and the information receiver (requester). Figure 1.4 - UMO and Requester Levels, presents Loop 2000A and Loop 2000B.

Figure 1.4 - UMO and Requester Levels

UMO and Requester Levels

Hierarchy Usage Chart for Transaction Participants
Various utilization management entities may appear in either Loop 2000A or Loop 2000B depending on the transaction usage. Table 1.3 - HL Information Sources and Receivers, has been included to better clarify the various entities involved in a health care services review inquiry. This matrix contains some examples where the UMO is one form of an HMO. Other examples can be constructed for other UMO environments. This matrix is by no means exhaustive.

Table 1.3 - HL Information Sources and Receivers

Transaction Use	HL UMO	HL Requester	Physical Transmitter	Physical Receiver
Specialist Inquiry on a Specialty Care Referral	HMO	SCP	SCP	HMO
Response to a Specialty Care Referral Inquiry	HMO	SCP	HMO	SCP
Hospital Inquiry on Admission Certification	HMO	HOSP	HOSP	HMO
Response to Admission Certification Inquiry	HMO	HOSP	HMO	HOSP
Specialist Inquiry on a Specialty Care Referral	PCP	SCP	SCP	PCP
Response to a Specialty Care Referral Inquiry	PCP	SCP	PCP	SCP
* UMO - Utilization Management Organization * PCP - Primary Care Provider * SCP - Specialty Care Provider * HOSP - Hospital * HMO - Health Maintenance Organization

UMO (Loop 2000A)
The Loop 2000A hierarchical level is used to identify the UMO. The UMO is generally the entity empowered to make a decision regarding the outcome of a health services review or the owner of information.

The following example demonstrates a minimum way of identifying a UMO.

HL*1**20*1~
NM1*X3*2******XX*1234567890~

Requester (Loop 2000B)
The Loop 2000B hierarchical level is used to designate the requester. The requester is generally the entity who is making the inquiry and for whom the response decision is intended.

On the response, this loop is required if the UMO system processed any of the information contained in the corresponding Loop 2000B of the inquiry. The UMO system must return a response or error response containing this loop. If the UMO system was unable to process any data beyond Loop 2000A of the inquiry, then this Loop 2000B is not required.

The following example demonstrates a minimum way of identifying a requester.

HL*2*1*21*1~
NM1*1P*1******24*000012345~

1.11.2 Patient (Loop 2000C and Loop 2000D)

Subscriber Loop 2000C and Dependent Loop 2000D identify the patient. Loop 2000C is always valued when inquiring on certifications for a specific patient and not used on global inquiries. Loop 2000C is required on a response to a patient specific inquiry when that response does not report a reject reason in a AAA segment in Loop 2000A or Loop 2000B. It is also required on global inquiry responses that return information on authorizations that match the inquiry criteria. Loop 2000D is used only when necessary to identify a patient who is a dependent. Figure 1.5 - Subscriber and Dependent Levels shows the structure of these loops.

Figure 1.5 - Subscriber and Dependent Levels

Subscriber and Dependent Levels

When the subscriber is the patient or when the patient has a unique identification number (different from the subscriber), only Loop 2000C is used. This situation is common when an insurance company issues a unique insurance identification card to each individual insured. In all other cases, Loop 2000C is used to identify the subscriber. Loop 2000D is used to identify the subscriber's dependent, who is the patient. This structure is more common in traditional group insurance where a patient is uniquely identified within the primary subscriber identifier.

When the 278 inquiry and response transaction set is used in batch mode, it can contain multiple patient requests. The recommended maximum is 99 but can be expanded by trading partner agreements. Refer to Section 1.3.2 - Other Usage Limitations for more information.

The Subscriber Name Loop 2010C and Dependent Name Loop 2010D contain the segments and data elements that hold the patient identification information. The NM1 and DMG segments contain all the data needed for the requester and UMO to identify the patient.

Identifying the Subscriber/Patient
In Subscriber Name Loop 2010C, the member ID (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID, are as follows:

Subscriber Last Name (NM103)
Subscriber First Name (NM104)
Subscriber Birth Date (DMG01 and DMG02).

The data requirements are the same for a dependent patient who has a unique identification number (different from the subscriber). When the subscriber is the patient or when the patient has a unique identification number (different from the subscriber), only Loop 2000C is used.

The following example demonstrates a sufficient way of identifying a patient who has a unique identification number.

HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~

Identifying the Dependent
If the dependent has not been issued a unique member ID, the Dependent Loop (2000D) is required in addition to Loop 2000C. Loop 2000C conveys insurance information and Loop 2000D conveys patient-related information. The maximum data elements that can be required by a UMO in Loop 2010C and 2010D to identify a patient are:

Loop 2010C
Subscriber's Member ID

Loop 2010D
Patient's First Name
Patient's Last Name
Patient's Date of Birth

If all four of these elements are present the UMO must generate a response if the patient is in the UMO's database. All UMOs are required to support the above search option if their system does not have unique Member Identifiers assigned to dependents.

The following example demonstrates a sufficient way of identifying a patient who is the dependent of a subscriber. The example also illustrates the use of other segments.

HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*23*1~
NM1*QC*1*SMITH*SEAN~
DMG*D8*20021229~

Patient Account Number
The requester (provider) can supply the patient account number as a supplemental identifier for the patient on the inquiry. This value is carried in a REF segment where REF01 = "EJ" in Loop 2000C - Subscriber or Loop 2000D - Dependent, whichever is the patient. However if the UMO receives the patient account number, they must return it in the 278 inquiry response transaction when a AAA reject is not returned at a higher level.

1.11.3 Patient Event (Loop 2000E)

A 278 inquiry transaction must include criteria to indicate the type of service review authorization to search for in the UMO system. The Patient Event loop is required on global inquiries and either the Patient Event loop or the Service loop (Loop 2000F) is required on patient inquiries. The Loop 2000E hierarchical level identifies the patient event associated with this health care services review inquiry. It identifies the category of service on the original request and whether the patient event concerns a referral to a specialist, specialty treatment, or an admission to a facility.

Figure 1.6 - Patient Event Level

Patient Event Level

Patient Event Inquiry Search Criteria
The requester can narrow the search by including additional patient event level search criteria in the inquiry such as the following:

status of the service review decision
previous review authorization number
previous review administrative reference number
dates associated with the patient event or the certification period
diagnosis associated with the original health care services review request
providers or specialty entities associated with this patient event, including the original referring or ordering provider

If the requester needs to further qualify the inquiry to search for specific procedures to be performed, the requester must identify these procedures at the Service Level (Loop 2000F).

Patient Event Inquiry Response - Authorizations Found
The inquiry response indicates if any authorizations are on file that meet the specifications contained in the inquiry. If this is a response to a global inquiry and authorizations exist that match the patient event specified, the response identifies one to many patients (Loops 2000C/2000D), where each patient loop contains at least one subordinate Patient Event loop (2000E). If this is a response to a patient-specific patient event inquiry and authorizations exist, the response includes one to many Patient Event loops associated with that patient. Each Patient Event loop of the response identifies a different service review authorization and may have subordinate Service loops that identify the specific services associated with that patient event. The response indicates the level of approval and any additional information available respecting the details of the authorization.

Patient Event Inquiry Response - Data Error or No Authorizations Found
The AAA segment is used only on the response. If the UMO system was unable to process the inquiry due to missing or invalid application data at this level, the UMO must return a 278 inquiry response containing a AAA segment at this level.

The AAA segment serves two purposes. It identifies the primary error condition in the Patient Event level on the inquiry that prohibits processing of the original inquiry. Also, if no authorizations are on file that meet the criteria specified at the Patient Event level of the inquiry, the UMO system must return an AAA segment at this level of the response to indicate that no authorizations match the inquiry criteria specified.

1.11.3.1 Specialty Care Referral Inquiries

Health care service review requests originally submitted on a 278 request transaction must specify a request category. You can specify the same service review request category on the inquiry to limit the number of authorizations in the UMO system that qualify in the inquiry result.

Specialty care referrals encompass those transactions where a provider requests permission to refer or send a patient to another provider, generally a specialist. These types of transactions generally are shared between a primary care physician and a UMO. However, they may just as easily be shared between any two providers or UMOs. A specialist (patient event or service provider) can use a specialty care referral inquiry to verify that a referral has been authorized for a specific patient. The original requesting provider can use the global inquiry to determine the status of all referral requests that the provider sent to the UMO previously. The requester can further qualify both patient specific and global inquiries with additional information on the specialist, specialty entity, or service type specified on the original request for referral.

The following example inquires on authorizations on file for a single office visit for a consultation at the provider's office.

Referral Inquiry

HL*4*3*EV*0~
UM*SC**3*11:B~

The UM segment is used to identify the type of health care services request.

UM01 = SC (Specialty Care Review)
UM03 = 3 (Consultation)
UM04 = 11:B (Physician's Office)

Generally, referral inquires include additional patient event inquiry criteria such as identification information about the consulting physician or specialty and the proposed date of the event. If the inquiry concerns referrals for a specific patient, then the Patient Event loop follows a parent Patient loop (2000C/2000D).

Referral Inquiry Response
The following sections describe the segments, in addition to those included on the inquiry, that may appear at the Patient Event level in the referral inquiry response.

The following response identifies an approved specialty care referral.

HL*4*3*EV*0~
UM*SC*I*3*11:B~
HCR*A1*0081096G~
HSD*VS*1~

Response Indicating Approval
The response includes the original service level details respecting the services requested. The HCR segment provides the results of the review as well as an associated reference number. This set of values indicates approval of the request in full. A reference number 0081096G is supplied and is critical if the provider wishes to initiate further transactions concerning this service.

HCR01 = A1 (Certified in Total)
HCR02 = 0081096G (Review Identification Number)

The UMO has authorized one visit (HSD*VS*1~).

Response Indicating Approval with Modification of Services
If the review entity approved the specialist visits specified on the original request but increased the number of visits to 4, the inquiry response would indicate this modification as follows:

HCR*A6*0081096G~
HSD*VS*4~

The HCR value "A6" indicates a status of modified.

Response Indicating Denial of Services
Some UMO systems retain information on file about denials. Many do not. The following is an example of the information returned on the inquiry response if the review entity denied the original service review request.

HL*4*3*EV*0~
UM*SC*I*3*11:B~
HCR*A3**0Y~
HSD*VS*1~

The A3 value indicates "not certified." In this example, the UMO has also supplied a Decision Reason Code (0Y), "Service Inconsistent with Patient's Age". Depending on UMO policy, the UMO might also return an administrative reference number (REF segment where REF01 = NT) that the requester can use to reference the transaction at a later date.

Inquiry on Request for Renewal
Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits on the period of treatment authorized and the UMO will authorize treatment for a limited period. For example, in a blanket authorization for allergy treatments as required for 30 days, at the end of the 30 days, the provider must request to renew the certification, not extend it. The UMO authorizes treatment for 30 day intervals, one interval at a time. In the original request for a renewal, the requester references the previous certification identifier and assigns UM02 the value "R". An inquiry can contain criteria to inquire on the status of the request for renewal, as follows:

HL*4*3*EV*0~
UM*SC*R~
REF*BB*AUT00001~

where UM02 = R (renewal) indicates that the requester wants to locate authorizations for renewal and REF01 = BB identifies AUT00001 as the previous review authorization number that was submitted on the request for renewal.

1.11.3.2 Health Services Review Inquiries

The term "health services review" identifies certifications for specific treatments or more extended care. Extended care refers to treatment for a condition requiring prolonged rehabilitation therapy. The requester can structure each inquiry to identify a certification related to a specific treatment, or extended care associated with a single patient event. If no specific dates are identified on the inquiry, multiple patient event certifications may be returned.

Health Service Review Inquiry
The UM segment identifies the type of health care services review inquiry. This limits the selection to only those certifications for the type of service specified. Use of this data element assumes that the original health care services review request specified the same service type. An example illustrating the use of UM03 to identify a service type follows.

UM*HS**6~

UM01 = HS (Health Services Review)
UM03 = 6 (Radiation Therapy)

Note that the original health care services review request might have specified a different service type or expressed the service as a specific procedure or set of procedures in the Service level segments of the original request. Use of this segment on the inquiry implies that only those certifications with an exact match on this value are returned by the UMO.

Health Service Review Inquiry Response
The uses of the Patient Event level on the health care services certification inquiry response are similar to those defined for the specialty care referral inquiry response with the exception of the following additional segments.

CR1, CR2, CR5, CR6 Segments
These segments provide more detailed information regarding ambulance, spinal manipulation, oxygen therapy, and home health care services. The inquiry response returns this information if it was submitted on the original health care services review request and is relevant to the certification information returned.

Inquiry Response for Spinal Manipulation Treatment
This is an example of a certification for spinal manipulation services (UM03 = 33) of the thoracic and lumbar section of the spine. It provides an example of the use of the CR2 segment. In this scenario, the UMO authorized 2 visits per week over a 3 month period. In addition, the certification specifies subluxation for Thoracic Eleven and Lumbar Five of the spine. In addition, the UMO might have authorized specific procedures in association with this treatment. The response returns procedure information at the Service level.

HL*4*3*EV*0~
UM*HS*I*33~
HCR*A1*00287654S~
HSD*VS*2*WK**34*3~
CR2***T11*L5~

The HSD Segment specifies the pattern of delivery for the authorized treatment. The spinal manipulation services include 2 visits per week over a 3 month period.

HSD01 = VS (Visits - Type of service count)
HSD02 = 2 (Number for quantity of services to be rendered in the interval specified in HSD03)
HSD03 = WK (Week - Timeframe for which the quantity of services will be rendered)
HSD05 = 34 (Month - Time period for which services will be continued)
HSD06 = 3 (Number of time periods requested in HSD05)

The CR2 Segment expresses the subluxation levels.
CR203 = T11 (Subluxation level code)
CR204 = L5 (Subluxation level code)

1.11.3.3 Admission Review Inquiries

The term "admission review" identifies requests for admission to a facility for treatment (pre-certification). The transaction set enables the requester to specify both the facility and associated physicians within the same transaction. Admission certification inquiries identify certifications for admission to a facility for treatment (pre-certification).

Admission Review Inquiry
The following example demonstrates an inquiry for authorizations for admission to a specific facility.

HL*4*3*EV*0~
UM*AR**2*21:B~
DTP*435*D8:20110820~
NM1*FA*2*ABC MEMORIAL HOSPITAL*****24*765432100~

The UM segment identifies the type of admission.
UM01 = AR (Admission Review)
UM03 = 2 (Surgical)
UM04 = 21:B (Hospital - Inpatient)

In this example, the additional elements clarify that the admission is for surgery that will take place in an inpatient setting. The NM1 segment identifies a specific facility as the provider of services for this patient event. The DTP identifies the date of admission.

NOTE
Use the Service Level (Loop 2000F) to inquire on authorizations for specific surgical procedures associated with this admission.

Admission Review Inquiry Response
The uses of the Patient Event level on the admission certification inquiry response are similar to those defined for the specialty care referral inquiry response.

1.11.3.4 Search for All Certifications for a Patient

The requester can elect to omit the request category (UM segment) from the Patient Event level of the inquiry. A PCP could use this type of inquiry to access all review and certification activity for the patient identified at the Patient level (2000C/2000D), as qualified by any one of the Patient Event level dates (DTP segments). The responder can limit the number of certifications returned on the response. For example, the UMO system might restrict responses to include the most recent 10 certifications that meet the search criteria.

All Certifications for a Patient Inquiry
If the inquiry was limited to a specific health care service review request date range, the Patient Event level would include a DTP segment but no UM segment. For example:

HL*4*3*EV*0~
DTP*881*RD8*20110101-20110830~

All Certifications for a Patient Inquiry Response
The all certifications for a patient inquiry response uses are identical to those described for the other types of inquiries. However, multiple Patient Event and Service level combinations may be returned representing multiple certifications for multiple patient events respecting the one patient.

1.11.4 Services (Loop 2000F)

On the 278 inquiry, the requester can use the Service level (Loop 2000F) to inquire on authorizations associated with specific procedures identified by procedure code. The requester can also identify service dates and service providers associated with the delivery of those procedures. Even if the inquiry does not include Service level information, any inquiry response that returns information on authorizations found may return Service level information that provides the details on the services associated with the patient event authorized. Some UMOs assign authorization to each service and others authorize the entire patient event. If the UMO authorizes at the service level, then each Service loop on the response can contain an HCR segment to return a specific review outcome and authorization number for each service.

Figure 1.7 - Service Level

Figure 1.7 - Service Level

As illustrated in Matrix 1 and Matrix 2, many of the segments used in Loop 2000F are the same as those available in Loop 2000E. For a detailed explanation of their use, refer to Section 1.11.3 - Patient Event (Loop 2000E).

Requesters can omit the Service level from the inquiry if they want to see all services associated with a patient event. On the inquiry response, the Service level can include all the pertinent information originally submitted as part of the original health care services review request.

Services Inquiry
The following demonstrates the Service level information for an inquiry for authorizations for a triple bypass venous graft. The inquiry has identified a specific patient in Loop 2000C and a patient event of admission review in Loop 2000E.

HL*5*4*SS*0~
SV2**HC:33510~

The SV2 segment specifies the CPT code for a triple bypass venous graft.

The UMO returns additional detail on the authorized service as follows:

HL54SS0~	This HL is subordinate to HL*4, the parent HL (which contains Patient Event information). This HL code is SS, identifying the service. This HL has no subordinate levels, or children.
UMHS*2~	This service review is for surgery.
HCRA1AUTH0002~	The UMO has approved the surgery in full and assigned it a separate certification number, AUTH0002.
DTP472D8*20050924~	The requested date for the surgery is September 24, 2005
SV2**HC:33510~	The surgeon will perform a triple bypass venous graft
NM1721WatsonSusan**** 34*987654321~	Dr. Watson is the surgeon
PRVPE203BS0133X~	Dr. Watson's specialty is thoracic cardiovascular surgery.

On the 278 inquiry response, the Service level (Loop 2000F) conveys the outcome of the service review decisions previously made about the patient for the period or services specified on the inquiry or as supported by the UMO.

The HI segment "Additional Service Description" is used to further define the service/procedure identified in UM03, SV1, SV2, SV3 or DRA. The segment uses SNOMED (and/or other as yet unspecified code set) codes to provide added granularity regarding the planned, requested or approved service. Use is particularly beneficial for services that are broadly defined such as Consultation, Targeted Medication Review, Chronic Care Coordination Services, Transitional Care Management and Medication Therapy Management.

For example:

UM03 = 3 (Consultation)
HI01-01 = AAA
HI01-02 = 422011000124105 (Geriatric syndrome education)
OR
Inquiry Request:
HI01-01 = AAA
HI01-02 = 431531000124101 (Health literacy assessment)

Inquiry Response:
SV101-01 = HC
SV01-02 = 99496 (Transitional Care Management Services)
HI01-01 = AAA
HI01-02 = 1871000124103 (Transition from acute care to home-health care)
HI02-01 = AAA
HI02-02 = 429111000124101 (Documentation of care summary)
HI03-01 = AAA
HI03-02 = 431531000124101 (Health literacy assessment)
HI04-01 = AAA
HI04-02 = 417011000124102 (Gastrointestinal disorder education)
HI05-01 = AAA
HI05-02 = (473230005 Gastrointestinal disorder medication review)

1.11.5 Summary Responses and Detail Responses

Section 1.10.1 - Overall Data Architecture describes the BHT06 values used to indicate if the response provides summary level or detail information on the authorizations found in the UMO system. Different UMOs may retain and return different levels of detail data related to the authorization. Use the situational rules in Section 2 to determine the specific data fields that the UMO can return on a detail response.

Patient Event level summary responses should return enough information to enable the recipient to send a follow up inquiry for additional detail. Minimum information for an authorized patient event must identify the patient, patient event category (UM01), authorization status (HCR01) and review identification number (HCR02), and a Patient Event level date if one has been assigned. This enables the requester to submit a follow-up inquiry using the patient identification information, request category, and previous review authorization number (REF) to request the details associated with the authorization.

Service level summary responses must return any summary information about the Patient Event in addition to the summary information associated with this service. Summary service authorization information must specify the procedure authorized and can include the authorization status (HCR01), review identification number (HCR02), and service date. The requester can use the review identification number returned at the Service level, or the review identification number returned at the Patient Event level along with the procedure code, to send a follow-up inquiry to access details about the procedure authorize.

2. Transaction Set

NOTE
See X12 documents X12.5, X12.6, and X12.59 to review transaction set structure, including descriptions of segments, levels, and loops.

2.1 Presentation Examples

The X12 standards are generic. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable.

This implementation guide uses a format that depicts both the generalized standard and the insurance industry-specific implementation. In this implementation guide, IMPLEMENTATION specifies the requirements for this implementation. X12 STANDARD is included as a reference only.

The transaction set presentation is comprised of two main sections with subsections within the main sections:

Transaction Set Listing

There are two sub-sections under this general title. The first sub-section concerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself.

This section lists the levels, loops, and segments contained in this implementation. It also serves as an index to the segment detail.

This section is included as a reference.

Segment Detail

There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail.

This section is included as a reference.

This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation.

This section specifies the implementation details of each data element.

These illustrations (Figures 2.1 through 2.5) are examples and are not extracted from the Section 2 detail in this implementation guide. Annotated illustrations, presented below in the same order they appear in this implementation guide, describe the format of the transaction set that follows.

Figure 2.1 - Transaction Set Key - Implementation

Transaction Set Key - Implementation

Figure 2.2 - Transaction Set Key - Standard

Transaction Set Key - Standard

Figure 2.3 - Segment Key - Implementation

Segment Key - Implementation

Figure 2.4 - Segment Key - Diagram

Segment Key - Diagram

Figure 2.5 - Segment Key - Element Summary

Segment Key - Element Summary

2.2.1 Industry Usage

Industry Usage describes when loops, segments, and elements are to be sent when complying with this implementation guide. The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational).

Required

This loop/segment/element must always be sent.

Required segments in Situational loops only occur when the loop is used.

Required elements in Situational segments only occur when the segment is used.

Required component elements in Situational composite elements only occur when the composite element is used.

Not Used

This element must never be sent.

Situational

Use of this loop/segment/element varies, depending on data content and business context as described in the defining rule. The defining rule is documented in a Situational Rule attached to the item.

There are two forms of Situational Rules.

"Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver."

The data qualified by such a situational rule cannot be required, requested or rejected by the receiver when the condition is not applicable. Transmission of this data is solely at the sender's discretion when the stated condition does not apply.

"Required when <explicit condition statement>. If not required by this implementation guide, do not send."

The data qualified by such a situational rule must not be sent except as described in the explicit condition statement.

2.2.1.1 Determining Transaction Compliance with Industry Usage Requirements

A transmitted transaction complies with the governing implementation guide when it satisfies the requirements as defined within the implementation guide. Specifically, the presence or absence of an item (loop, segment, or element) complies with the industry usage specified by this implementation guide according to the following table.

Industry Usage	Business Condition is	Item is	Transaction Complies with Implementation Guide?
Required	N/A	Sent	Yes
Required	N/A	Not Sent	No
Not Used	N/A	Sent	No
Not Used	N/A	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	Yes
	Not True	Not Sent	Yes
Situational (Required when <explicit condition statement>. If not required by this implementation guide, do not send.)	True	Sent	Yes
	True	Not Sent	No
	Not True	Sent	No
	Not True	Not Sent	Yes

2.2.2 Loops

Loop requirements depend on the context or location of the loop within the transaction. See Appendix B for more information on loops.

A nested loop can be used only when the associated higher level loop is used.
The usage of a loop is the same as the usage of its beginning segment.
- If a loop's beginning segment is Required, the loop is Required and must occur at least once unless it is nested in a loop that is not being used.
- If a loop's beginning segment is Situational, the loop is Situational.
Subsequent segments within a loop can be sent only when the beginning segment is used.
Required segments in Situational loops occur only when the loop is used.

2.4 278 Inquiry Detail

This section specifies the segments, data elements, and codes for this implementation. Refer to Section 2.1 Presentation Examples for detailed information on the components of the Segment Detail section.

SEGMENT DETAIL

ST - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment indicates the start of a Healthcare Services Review Inquiry transaction set with all of the supporting detail information. This transaction set is the electronic equivalent of a phone, fax, or paper-based Utilization Management review inquiry.

TR3 Example:

ST✱278✱0002✱008020X327~


DIAGRAM

✱

ST01		143
TS ID Code
M 1	ID	3/3

✱

ST02		329
TS Control Number
M 1	AN	4/9

✱

ST03		1705
Imple Conv Reference
O 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

ST01

143

Transaction Set Identifier Code

M 1

3/3

Code identifying a Transaction Set

CODE

DEFINITION

278

Health Care Services Review Information

REQUIRED

ST02

329

Transaction Set Control Number

M 1

4/9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

REQUIRED

ST03

1705

Implementation Convention Reference

O 1

1/35

Reference assigned to identify Implementation Convention

This element must be populated with the guide identifier named in Section 1.2.

This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

SEGMENT DETAIL

BHT - BEGINNING OF HIERARCHICAL TRANSACTION

X12 Name:

Beginning of Hierarchical Transaction

X12 Purpose:

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

Segment Repeat:

Usage:

REQUIRED

TR3 Example:

BHT✱0007✱28✱199800114000001✱20220101✱1400✱RD~


DIAGRAM

BHT

✱

BHT01		1005
Hierarch Struct Code
M 1	ID	4/4

✱

BHT02		353
TS Purpose Code
M 1	ID	2/2

✱

BHT03		127
Reference Ident
O 1	AN	1/80

✱

BHT04		373
Date
O 1	DT	8/8

✱

BHT05		337
Time
O 1	TM	4/8

✱

BHT06		640
Transaction Type Code
O 1	ID	2/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

BHT01

1005

Hierarchical Structure Code

M 1

4/4

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

CODE

DEFINITION

0007

Information Source, Information Receiver, Subscriber, Dependent, Event, Services

REQUIRED

BHT02

353

Transaction Set Purpose Code

M 1

2/2

Code identifying purpose of transaction set

CODE

DEFINITION

Query

Use when inquiring on authorizations associated with a specific patient.

Historical Inquiry

Use when the transaction is a global inquiry for the status of authorizations associated with multiple patients.

REQUIRED

BHT03

127

Reference Identification

O 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.

INDUSTRY NAME: Submitter Transaction Identifier

Use this element to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. If the inquiry transaction is processed in real-time, the respondent must return this value in the corresponding 278 response transaction's BHT03. This identifier will only be returned by the last entity to handle the 278. This identifier will not be passed through the complete life of the transaction. All recipients of real-time 278 inquiry transactions are required to return the Submitter Transaction Identifier in their 278 response.

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

REQUIRED

BHT04

373

Date

O 1

8/8

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: BHT04 is the date the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Date

REQUIRED

BHT05

337

Time

O 1

4/8

SEMANTIC: BHT05 is the time the transaction was created within the business application system.

INDUSTRY NAME: Transaction Set Creation Time

SITUATIONAL

BHT06

640

Transaction Type Code

O 1

2/2

Code specifying the type of transaction

SITUATIONAL RULE: Required when BHT02 = 51 and the requester has a preference for full detail or summary responses. If not required by this implementation guide, do not send.

This implementation guide does not require the UMO system to support both summary and detail responses. Refer to Section 1.11.5 for a description of the contents of these responses.

CODE

DEFINITION

Returns Detail

Use when requesting the full details for the available records on the UMO system based on the search criteria provided.

Sort and Segregate Detail

Use when requesting a summary of information for the available records on the UMO system based on the search criteria provided.

SEGMENT DETAIL

HL - UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000A — UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment indicates the information source hierarchical level. For an inquiry transaction, this segment identifies the payer, HMO, or other utilization management organization that is the source of service review decision.

TR3 Example:

HL✱1✱✱20✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
~~Hierarch~~ ~~Parent ID~~
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

NOT USED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Source

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

NM1 - UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010A — UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment identifies the source of information. For an inquiry transaction this names the payer or utilization review organization responsible for the health care service review decision.

TR3 Example:

NM1✱X3✱2✱ABC PAYER✱✱✱✱✱46✱123450000~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Third-Party Administrator

Employer

Payer

Utilization Management Organization

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the UMO. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is valued and the reviewing entity is an individual (NM102 = 1), such as a primary care provider. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Utilization Management Organization (UMO) Name Suffix

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Electronic Transmitter Identification Number (ETIN)

Payor Identification

Use when UMO is a payer and XV is not used.

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Utilization Management Organization (UMO) Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

HL - REQUESTER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000B — REQUESTER LEVEL
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment indicates the healthcare services review information receiver. For inquiry transactions, this corresponds to the identification of the entity initiating the inquiry.

TR3 Example:

HL✱2✱1✱21✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Information Receiver

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

NM1 - REQUESTER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010B — REQUESTER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment identifies the entity requesting the service review information.

TR3 Example:

NM1✱1P✱1✱WHITE✱CHRIS✱✱✱✱XX✱1234567890~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Provider

Federal, State, County or City Facility

Third-Party Administrator

Employer

Facility

Payer

Utilization Management Organization

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed to identify the requester. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM103 is present and NM102 = 1. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Payor Identification

Use when UMO is a payer and XV is not used.

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE 540: Health Plan Identifier (HPID)

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Requester Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - REQUESTER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010B — REQUESTER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Example:

REF✱ZH✱A12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Use when reporting the physician, clinic, or group practice.

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when reporting the requester/provider ID as assigned by the UMO identified in Loop 2000A.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Requester Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

N3 - REQUESTER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010B — REQUESTER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use to identify a specific location when the requester has multiple locations and authority varies based on location.

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Requester Address Line

Use this element for the first line of the requester's address.

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Address Line

SEGMENT DETAIL

N4 - REQUESTER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	E0308 Only one of N403 or N408 may be present.
3.	C0605 If N406 is present, then N405 is required.
4.	C0704 If N407 is present, then N404 is required.

Loop:

2010B — REQUESTER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the location is used as identification information for the requester. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
X 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

✱

N408		1702
~~Postal Code~~ ~~Formatted~~
X 1	AN	3/20

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Requester City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Requester Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Requester Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Requester Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N408

1702

Postal Code-Formatted

X 1

3/20

SEGMENT DETAIL

PRV - REQUESTER PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2010B — REQUESTER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PC✱PXC✱203BS0133X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/80

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Consulting

Covering

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

HL - SUBSCRIBER LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000C — SUBSCRIBER LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on the status of authorizations for a specific patient. If not required by this implementation guide, do not send.

TR3 Notes:


1.	The Subscriber Hierarchical level (Loop 2000C) is required if the inquiry concerns authorizations for a specific patient. Situational use of this segment enables the requester to create an inquiry that does not specify the name or member information for each patient. If the requester omits this loop on the inquiry, the requester can inquire on the status of all the health care services review requests for which the provider is the original requesting provider, the patient event/service provider, or primary care provider of record for the patient(s). For the UMO to respond to this type of inquiry, the UMO must provide other methods of access to authorizations on file in addition to access by member ID. This guide does not require UMOs to support this level of inquiry. Support at this level is at the discretion of the UMO. The UMO must authenticate that the entity initiating the inquiry has a relationship with this patient that authorizes the requester to receive this information.

2.	This segment indicates the subscriber hierarchical level. This segment corresponds to the identification of the subscriber or individual insured member. The subscriber could also be the patient. If the subscriber is the patient or the patient has a unique insurance identifier, the dependent hierarchical level (Loop 2000D) is not used.

3.	A transaction submitted in real-time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.

4.	Patient Event Loop 2000E must be valued if Loop 2000C is not valued.

TR3 Example:

HL✱3✱2✱22✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Subscriber

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

NM1 - SUBSCRIBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010C — SUBSCRIBER NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment conveys the name and identification number of the subscriber (who may also be the patient), or the Property & Casualty (including Workers' Compensation) entity.

2.	The Member Identification Number (NM108/NM109) is required and may be adequate to identify the subscriber to the UMO. However, the UMO can require additional information. The maximum data elements that the UMO can require to identify the subscriber, in addition to the member ID are as follows: Subscriber Last Name (NM103) Subscriber First Name (NM104) Subscriber Birth Date (DMG01 and DMG02)

3.	Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

4.	When a Property & Casualty (including Workers' Compensation) entity is the Subscriber, value the Entity Type Qualifier to 2 and the associated Federal Tax ID.

TR3 Example:

NM1✱IL✱1✱DOE✱JOHN✱T✱✱JR✱MI✱123456~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
Name Prefix
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Insured or Subscriber

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Subscriber Middle Name or Initial

SITUATIONAL

NM106

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when subscriber's military title or rank is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Prefix

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the suffix of an individual's name is needed to further identify the subscriber; e.g., Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Subscriber Name Suffix

REQUIRED

NM108

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when NM102 = 2.

Standard Unique Health Identifier for each Individual in the United States

Member Identification Number

Use when reporting the subscriber's identification number as assigned by the payer.

REQUIRED

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Subscriber Primary Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - SUBSCRIBER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to provide a supplemental identifier for the subscriber. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number is provided in the NM1 segment as a Member Identification Number when it is the primary number by which the UMO knows the member (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless it is different from the Member Identification Number provided in the NM1 segment.

2.	If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱1W✱123456789~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Use when you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

Branch Identifier

Group Number

Department Number

Patient Account Number

Health Insurance Claim (HIC) Number

Identity Card Number

Use when the Identity Card Number differs from the Member Identification Number (MI) in NM108.

Insurance Policy Number

Plan Network Identification Number

Medicaid Recipient Identification Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DMG - SUBSCRIBER DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

1.	P0102 If either DMG01 or DMG02 is present, then the other is required.
2.	P1011 If either DMG10 or DMG11 is present, then the other is required.
3.	C1105 If DMG11 is present, then DMG05 is required.

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when birth date is needed to identify the subscriber/patient. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19580322~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
~~Gender~~ ~~Code~~
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 25

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

✱

DMG12		26
~~Country~~ ~~Code~~
O 1	ID	2/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DMG02

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Subscriber Birth Date

NOT USED

DMG03

1068

Gender Code

O 1

1/1

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 25

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

NOT USED

DMG12

Country Code

O 1

2/3

SEGMENT DETAIL

INS - SUBSCRIBER RELATIONSHIP

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

1.	P1112 If either INS11 or INS12 is present, then the other is required.

Loop:

2010C — SUBSCRIBER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when subscriber's military role is needed by the UMO to further identify the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

INS✱Y✱18✱✱✱✱✱✱AO~


DIAGRAM

INS

✱

INS01		1073
Yes/No Cond Resp Code
M 1	ID	1/1

✱

INS02		1069
Individual Relat Code
M 1	ID	2/2

✱

INS03		875
~~Maintenance~~ ~~Type Code~~
O 1	ID	3/3

✱

INS04		1203
~~Maintain~~ ~~Reason Code~~
O 1	ID	2/3

✱

INS05		1216
~~Benefit~~ ~~Status Code~~
O 1	ID	1/1

✱

INS06		C052
~~Medicare~~ ~~Status Code~~
O 1

✱

INS07		1219
~~COBRA Qual~~ ~~Event Code~~
O 1	ID	1/2

✱

INS08		584
Employment Status Code
O 1	ID	2/2

✱

INS09		1220
~~Student~~ ~~Status Code~~
O 1	ID	1/1

✱

INS10		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

INS11		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

INS12		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

INS13		1165
~~Confident~~ ~~Code~~
O 1	ID	1/1

✱

INS14		19
~~City~~ ~~Name~~
O 1	AN	2/30

✱

INS15		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

INS16		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

INS17		1470
~~Number~~
O 1	N0	1/9

✱

INS18		1792
~~Chge Identi~~ ~~Info Code~~
O 20	ID	1/2

✱

INS19		1793
~~Prov Netwrk~~ ~~Info Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

INS01

1073

Yes/No Condition or Response Code

M 1

1/1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Insured Indicator

CODE

DEFINITION

Yes

REQUIRED

INS02

1069

Individual Relationship Code

M 1

2/2

Code indicating the relationship between two individuals or entities

CODE

DEFINITION

Self

NOT USED

INS03

875

Maintenance Type Code

O 1

3/3

NOT USED

INS04

1203

Maintenance Reason Code

O 1

2/3

NOT USED

INS05

1216

Benefit Status Code

O 1

1/1

NOT USED

INS06

C052

Medicare Status Code

O 1

NOT USED

INS07

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying

O 1

1/2

REQUIRED

INS08

584

Employment Status Code

O 1

2/2

Code indicating the general employment status of an employee/claimant

Use to qualify the patient's relationship to the military.

CODE

DEFINITION

Active Military - Overseas

Active Military - USA

Deceased

Retired Military - USA

NOT USED

INS09

1220

Student Status Code

O 1

1/1

NOT USED

INS10

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

INS11

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

INS12

1251

Date Time Period

X 1

1/35

NOT USED

INS13

1165

Confidentiality Code

O 1

1/1

NOT USED

INS14

City Name

O 1

2/30

NOT USED

INS15

156

State or Province Code

O 1

2/2

NOT USED

INS16

Country Code

O 1

2/3

NOT USED

INS17

1470

Number

O 1

1/9

NOT USED

INS18

1792

Changed Identifying Information Code

O 20

1/2

NOT USED

INS19

1793

Provider Network Status Information Code

O 1

1/2

SEGMENT DETAIL

HL - DEPENDENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000D — DEPENDENT LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	If the patient has a unique member ID, use Loop 2000C to identify the patient.

2.	A transaction submitted in real-time mode can inquire on a maximum of one patient. A transaction submitted in batch mode can contain a maximum of ninety-nine patient requests. Each patient is defined as either one subscriber loop if the member is the patient, or one subscriber loop and one dependent loop if the dependent is the patient.

TR3 Example:

HL✱4✱3✱23✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Dependent

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

NM1 - DEPENDENT NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010D — DEPENDENT NAME
Loop Repeat: 1

Segment Repeat:

Usage:

REQUIRED

TR3 Notes:


1.	This segment conveys the name of the dependent who is the patient.

2.	The maximum data elements in Loop 2010D that can be required by a UMO to identify a dependent are as follows: Dependent Last Name (NM103) Dependent First Name (NM104) Dependent Birth Date (DMG01 and DMG02)

3.	Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

NM1✱QC✱1✱DOE✱SALLY✱J~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
~~ID Code~~ ~~Qualifier~~
X 1	ID	1/2

✱

NM109		67
ID ~~Code~~
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Patient

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent Last Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when name information is needed by the UMO to identify the dependent. If not required by this implementation guide, do not send.

INDUSTRY NAME: Dependent First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

INDUSTRY NAME: Dependent Middle Name or Initial

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Dependent Name Suffix

NOT USED

NM108

Identification Code Qualifier

X 1

1/2

NOT USED

NM109

Identification Code

X 1

2/80

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - DEPENDENT SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010D — DEPENDENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when used by the requester to identify the dependent to the UMO. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use the Subscriber Supplemental Identifier (REF) segment in Loop 2010C for supplemental identifiers related to the subscriber's policy or group number.

2.	If the requester values this segment with the Patient Account Number (REF01 = "EJ") on the request, the UMO is required to return the same value in this segment on the response.

TR3 Example:

REF✱EJ✱660415~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Employee Identification Number

Patient Account Number

Social Security Number

Agency Claim Number

Use when reporting the Property & Casualty claim number.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Dependent Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DMG - DEPENDENT DEMOGRAPHIC INFORMATION

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

1.	P0102 If either DMG01 or DMG02 is present, then the other is required.
2.	P1011 If either DMG10 or DMG11 is present, then the other is required.
3.	C1105 If DMG11 is present, then DMG05 is required.

Loop:

2010D — DEPENDENT NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when birth date is needed to identify the dependent. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Refer to the subsection Identifying the Subscriber/Patient within Section 1.11.2 Patient (Loop 2000C and Loop 2000D) for specific information on how to identify an individual to a UMO.

TR3 Example:

DMG✱D8✱19580322~


DIAGRAM

DMG

✱

DMG01		1250
Date Time Format Qual
X 1	ID	2/3

✱

DMG02		1251
Date Time Period
X 1	AN	1/35

✱

DMG03		1068
~~Gender~~ ~~Code~~
O 1	ID	1/1

✱

DMG04		1067
~~Marital~~ ~~Status Code~~
O 1	ID	1/1

✱

DMG05		C056
~~Comp Race~~ ~~or Ethn Inf~~
X 25

✱

DMG06		1066
~~Citizenship~~ ~~Status Code~~
O 1	ID	1/2

✱

DMG07		26
~~Country~~ ~~Code~~
O 1	ID	2/3

✱

DMG08		659
~~Basis of~~ ~~Verif Code~~
O 1	ID	1/2

✱

DMG09		380
~~Quantity~~
O 1	R	1/15

✱

DMG10		1270
~~Code List~~ ~~Qual Code~~
X 1	ID	1/3

✱

DMG11		1271
~~Industry~~ ~~Code~~
X 1	AN	1/30

✱

DMG12		26
~~Country~~ ~~Code~~
O 1	ID	2/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DMG01

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DMG02

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEGMENT SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

INDUSTRY NAME: Dependent Birth Date

NOT USED

DMG03

1068

Gender Code

O 1

1/1

NOT USED

DMG04

1067

Marital Status Code

O 1

1/1

NOT USED

DMG05

C056

Composite Race or Ethnicity Information

X 25

NOT USED

DMG06

1066

Citizenship Status Code

O 1

1/2

NOT USED

DMG07

Country Code

O 1

2/3

NOT USED

DMG08

659

Basis of Verification Code

O 1

1/2

NOT USED

DMG09

380

Quantity

O 1

1/15

NOT USED

DMG10

1270

Code List Qualifier Code

X 1

1/3

NOT USED

DMG11

1271

Industry Code

X 1

1/30

NOT USED

DMG12

Country Code

O 1

2/3

SEGMENT DETAIL

HL - PATIENT EVENT LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000E — PATIENT EVENT LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	The Patient Event level enables you to further qualify your inquiry. Use this loop to identify an existing patient event level authorization associated with this inquiry.

2.	When you use this loop on the inquiry, you limit the range of authorizations that meet the specifications entered. Use of this loop also ensures that the response from the UMO contains only those authorizations that meet the criteria you provided.

3.	A transaction submitted in real time mode can contain a maximum of one global inquiry. A transaction submitted in batch mode can contain a maximum of five global inquiries. Refer to section 1.4.2 for a description of global inquiry.

TR3 Example:

HL✱5✱4✱EV✱1~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

INDUSTRY NAME: Hierarchical Parent ID Number

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

INDUSTRY NAME: Hierarchical ID Number

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Event

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

Additional Subordinate HL Data Segment in This Hierarchical Structure.

SEGMENT DETAIL

TRN - PATIENT EVENT TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.

2.	If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.

TR3 Example:

TRN✱1✱2001042801✱9012345678✱CARDIOLOGY~


DIAGRAM

TRN

✱

TRN01		481
Trace Type Code
M 1	ID	1/2

✱

TRN02		127
Reference Ident
M 1	AN	1/80

✱

TRN03		509
Originating Company ID
O 1	AN	10/10

✱

TRN04		127
Reference Ident
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TRN01

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

REQUIRED

TRN02

127

Reference Identification

M 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Patient Event Trace Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

REQUIRED

TRN03

509

Originating Company Identifier

O 1

10/10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

Use this element to identify the organization that assigned this trace number. TRN03 must be completed to aid requesters and clearinghouses in identifying their TRN in the 278 response.

The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used, or a "9" if a user assigned identifier is used.

SITUATIONAL

TRN04

127

Reference Identification

O 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

SEGMENT DETAIL

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Value this segment if you want to limit the inquiry to only referrals, or admission certifications, or health care service certifications.

TR3 Example:

UM✱SC✱I✱3~


DIAGRAM

✱

UM01		1525
Request Categ Code
M 1	ID	1/2

✱

UM02		1322
Certificate Type Code
O 1	ID	1/1

✱

UM03		1271
Industry Code
O 1	AN	1/30

✱

UM04		C023
Health Care Serv Loc.
O 1

✱

UM05		C024
~~Related~~ ~~Causes Info~~
O 1

✱

UM06		1338
~~Level of~~ ~~Serv Code~~
O 1	ID	1/3

✱

UM07		1213
~~Current~~ ~~Health Code~~
O 1	ID	1/1

✱

UM08		923
~~Prognosis~~ ~~Code~~
O 1	ID	1/1

✱

UM09		1363
~~Release of~~ ~~Info Code~~
O 1	ID	1/1

✱

UM10		1514
~~Delay~~ ~~Reason Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

UM01

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Admission Review

Use when limiting the inquiry to information on requests for admission to a facility.

Health Services Review

Use when reporting services related to an episode of care.

Individual

Use when reporting on the status or existence of service reservations.

Specialty Care Review

Use when reporting a referral to a specialty provider.

SITUATIONAL

UM02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

Use when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Use when requesting the UMO to reconsider a previously denied referral or certification.

Renewal

Revised

Use when changing the specifics of a previously submitted request for which services have not been rendered.

SITUATIONAL

UM03

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to only those authorizations for the type of service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

SITUATIONAL

UM04

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

CLICK TO SHOW/HIDE: X12 Composite Syntax Notes

SITUATIONAL RULE: Required when the requester needs to limit the inquiry to only those certifications for the facility type specified. If not required by this implementation guide, do not send.

REQUIRED

UM04-01

1331

Facility Code Value

1/3

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

REQUIRED

UM04-02

1332

Facility Code Qualifier

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

NOT USED

UM04-03

1325

Claim Frequency Type Code

1/1

NOT USED

UM05

C024

Related Causes Information

O 1

NOT USED

UM06

1338

Level of Service Code

O 1

1/3

NOT USED

UM07

1213

Current Health Condition Code

O 1

1/1

NOT USED

UM08

923

Prognosis Code

O 1

1/1

NOT USED

UM09

1363

Release of Information Code

O 1

1/1

NOT USED

UM10

1514

Delay Reason Code

O 1

1/2

SEGMENT DETAIL

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the requester needs to limit the inquiry to only those health care service reviews on file at the UMO with a specific status. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use of HCR01 (action code) to limit the responses to only those authorizations that match a specific action/status may omit authorizations for which the status has changed. For example, an inquiry on all health care services reviews with a pended status will not return information on a review that has moved from a pended to a final status.

TR3 Example:

HCR✱A1~


DIAGRAM

HCR

✱

HCR01		306
Action Code
M 1	ID	1/2

✱

HCR02		127
~~Reference~~ ~~Ident~~
O 1	AN	1/80

✱

HCR03		1271
~~Industry~~ ~~Code~~
O 5	AN	1/30

✱

HCR04		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HCR01

306

Action Code

M 1

1/2

Code indicating type of action

ALIAS: Certification Action Code

CODE

DEFINITION

Complete

Use when the inquiry is for authorizations with a status of complete. For the UMO, the authorization is complete at the time the claim is received and recorded.

Term Expired

Use when the inquiry is for authorizations with a status of expired.

Certified in total

Certified - partial

Use when the inquiry is for authorizations with a status of partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Not Certified

Pended

Modified

Cancelled

Contact Payer

NOT USED

HCR02

127

Reference Identification

O 1

1/80

NOT USED

HCR03

1271

Industry Code

O 5

1/30

NOT USED

HCR04

1073

Yes/No Condition or Response Code

O 1

1/1

SEGMENT DETAIL

REF - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	This is the certification number previously assigned by the UMO to the original service review outcome associated with this inquiry. This is not the trace number assigned by the requester.

2.	If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.

TR3 Example:

REF✱BB✱A123~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

REF✱NT✱123Z~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DTP - ACCIDENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱439✱D8✱20221030~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

439

Accident

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Accident Date

SEGMENT DETAIL

DTP - EVENT DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	If UM01 = AR use Admit Date.

2.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱AAH✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AAH

Event

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Event Date

SEGMENT DETAIL

DTP - ADMISSION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Use in conjunction with UM01 = "AR" (admission review) to limit the inquiry to patient events associated with requests for admission to a facility.

2.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱435✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

435

Admission

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Use when needed to report a range of dates when admission can occur.

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Admission Date

SEGMENT DETAIL

DTP - DISCHARGE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱096✱D8✱20220930~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

096

Discharge

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Date and Time Expressed in Format CCYYMMDDHHMM

DTS

Range of Date and Time Expressed in Format CCYYMMDDHHMMSS-CCYYMMDDHHMMSS

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Discharge Date

SEGMENT DETAIL

DTP - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the requester needs to limit the inquiry to those authorizations issued on a specific date or within a specific date range. If not required by this implementation guide, do not send.

TR3 Notes:


1.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱102✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Issue Date

SEGMENT DETAIL

DTP - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱036✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Expiration Date

SEGMENT DETAIL

DTP - CERTIFICATION EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Effective Date

SEGMENT DETAIL

DTP - HEALTH CARE SERVICES REVIEW REQUEST DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	The date when the requester initiated the health care services review request might not be consistent with the date when the UMO received the health care services review request. Use of this segment implies that only those certifications that match on this value are returned by the UMO.

2.	A global inquiry must value at least one DTP segment in Loop 2000E if the Service Date in Loop 2000F is not valued.

TR3 Example:

DTP✱881✱D8✱20221223~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

881

Request

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Health Care Services Review Request Date

SEGMENT DETAIL

HI - PATIENT SYMPTOMS, DIAGNOSIS, COMPLAINTS

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

2000E — PATIENT EVENT LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.

2.	There are 2 repetitions of the HI segment to allow for 24 possible occurrences of ICD Diagnosis code information. The first iteration would contain diagnosis code 1-12. When used, the second iteration would contain diagnosis codes 13-24.

TR3 Example:

HI✱ABF:H16013~


DIAGRAM

✱

HI01		C022
Health Care Code Info.
M 1

✱

HI02		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI03		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI04		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI05		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI06		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI07		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI08		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI09		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI10		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI11		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI12		C022
~~Health Care~~ ~~Code Info.~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HI01

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

CLICK TO SHOW/HIDE: X12 Composite Comments

REQUIRED

HI01-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

ABF

International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABJ

International Classification of Diseases Clinical Modification (ICD-10-CM) Admitting Diagnosis

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

ABK

International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

APR

International Classification of Diseases Clinical Modification (ICD-10-CM) Patient's Reason for Visit

CODE SOURCE 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Diagnosis Related Group (DRG)

REQUIRED

HI01-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Diagnosis Code

NOT USED

HI01-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI01-04

1251

Date Time Period

1/35

NOT USED

HI01-05

782

Monetary Amount

1/18

NOT USED

HI01-06

380

Quantity

1/15

NOT USED

HI01-07

799

Version Identifier

1/30

NOT USED

HI01-08

1271

Industry Code

1/30

NOT USED

HI01-09

1271

Industry Code

1/30

NOT USED

HI01-10

1271

Industry Code

1/30

NOT USED

HI02

C022

Health Care Code Information

O 1

NOT USED

HI03

C022

Health Care Code Information

O 1

NOT USED

HI04

C022

Health Care Code Information

O 1

NOT USED

HI05

C022

Health Care Code Information

O 1

NOT USED

HI06

C022

Health Care Code Information

O 1

NOT USED

HI07

C022

Health Care Code Information

O 1

NOT USED

HI08

C022

Health Care Code Information

O 1

NOT USED

HI09

C022

Health Care Code Information

O 1

NOT USED

HI10

C022

Health Care Code Information

O 1

NOT USED

HI11

C022

Health Care Code Information

O 1

NOT USED

HI12

C022

Health Care Code Information

O 1

SEGMENT DETAIL

NM1 - PATIENT EVENT PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

1.	P0809 If either NM108 or NM109 is present, then the other is required.
2.	C1110 If NM111 is present, then NM110 is required.
3.	C1203 If NM112 is present, then NM103 is required.

Loop:

2010EA — PATIENT EVENT PROVIDER NAME
Loop Repeat: 14

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Use this segment to convey the name and identification number of the service provider (person, group, or facility) specialist, or specialty entity to provide services to the patient.

TR3 Example:

NM1✱SJ✱1✱WATSON✱SUSAN✱✱✱✱XX✱1234567890~


DIAGRAM

NM1

✱

NM101		98
Entity ID Code
M 1	ID	2/3

✱

NM102		1065
Entity Type Qualifier
M 1	ID	1/1

✱

NM103		1035
Name Last/ Org Name
X 1	AN	1/80

✱

NM104		1036
Name First
O 1	AN	1/35

✱

NM105		1037
Name Middle
O 1	AN	1/25

✱

NM106		1038
~~Name~~ ~~Prefix~~
O 1	AN	1/10

✱

NM107		1039
Name Suffix
O 1	AN	1/10

✱

NM108		66
ID Code Qualifier
X 1	ID	1/2

✱

NM109		67
ID Code
X 1	AN	2/80

✱

NM110		706
~~Entity~~ ~~Relat Code~~
X 1	ID	2/2

✱

NM111		98
~~Entity ID~~ ~~Code~~
O 1	ID	2/3

✱

NM112		1035
~~Name Last/~~ ~~Org Name~~
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

NM101

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Attending Physician

Operating Physician

Other Physician

Service Location

Admitting Physician

Assistant Surgeon

Ordering Physician

Referring Provider

Facility

Clinic

Primary Care Provider

Purchase Service Provider

Group Practice

Service Provider

REQUIRED

NM102

1065

Entity Type Qualifier

M 1

1/1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

SITUATIONAL

NM103

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Patient Event Provider Last or Organization Name

SITUATIONAL

NM104

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the service provider is a specific person (NM102 = 1) and NM103 is present. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider First Name

SITUATIONAL

NM105

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM104 is present and the middle name/initial of the person is known. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Middle Name

NOT USED

NM106

1038

Name Prefix

O 1

1/10

SITUATIONAL

NM107

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM104 is valued and the suffix of the individual's name is known; e.g. Sr., Jr., or III. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Name Suffix

SITUATIONAL

NM108

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when NM109 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE 537: National Provider Identifier (NPI)

SITUATIONAL

NM109

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Patient Event Provider Identifier

NOT USED

NM110

706

Entity Relationship Code

X 1

2/2

NOT USED

NM111

Entity Identifier Code

O 1

2/3

NOT USED

NM112

1035

Name Last or Organization Name

O 1

1/80

SEGMENT DETAIL

REF - PATIENT EVENT PROVIDER SUPPLEMENTAL IDENTIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when NM109 of this loop is not used and an identifier is necessary for the receiver to identify the provider. If not required by this implementation guide, do not send.

TR3 Notes:


1.	Use the NM108 and NM109 in the corresponding NM1 segment for the NPI identifier and number.

TR3 Example:

REF✱ZH✱A12345~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
Description
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Facility ID Number

Employer's Identification Number

Use when NM108 does not equal 24 (Employer's Identification Number)

Provider Site Number

Provider Plan Network Identification Number

Facility Network Identification Number

Social Security Number

Carrier Assigned Reference Number

Use when the event provider has not been assigned an NPI and the UMO identified in loop 2010A has assigned its own identifier for this provider.

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Patient Event Provider Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

SITUATIONAL

REF03

352

Description

X 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B to report the two character state ID of the state assigning the State License Number. If not required by this implementation guide, do not send.

INDUSTRY NAME: License Number State Code

See Code Source 22: State and Outlying Areas of the US.

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

N3 - PATIENT EVENT PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

N3✱123 MAIN STREET~


DIAGRAM

✱

N301		166
Address Information
M 1	AN	1/55

✱

N302		166
Address Information
O 1	AN	1/55

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N301

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Patient Event Provider Address Line

Use this element for the first line of the provider's address.

SITUATIONAL

N302

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required when a second address line is needed. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Address Line

SEGMENT DETAIL

N4 - PATIENT EVENT PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

1.	E0207 Only one of N402 or N407 may be present.
2.	E0308 Only one of N403 or N408 may be present.
3.	C0605 If N406 is present, then N405 is required.
4.	C0704 If N407 is present, then N404 is required.

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~


DIAGRAM

✱

N401		19
City Name
O 1	AN	2/30

✱

N402		156
State or Prov Code
X 1	ID	2/2

✱

N403		116
Postal Code
X 1	ID	3/15

✱

N404		26
Country Code
X 1	ID	2/3

✱

N405		309
~~Location~~ ~~Qualifier~~
X 1	ID	1/2

✱

N406		310
~~Location~~ ~~Identifier~~
O 1	AN	1/30

✱

N407		1715
Country Sub Code
X 1	ID	1/3

✱

N408		1702
~~Postal Code~~ ~~Formatted~~
X 1	AN	3/20

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

N401

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Patient Event Provider City Name

SITUATIONAL

N402

156

State or Province Code

X 1

2/2

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL

N403

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Patient Event Provider Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code

CODE SOURCE 932: Universal Postal Codes

SITUATIONAL

N404

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Patient Event Provider Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N405

309

Location Qualifier

X 1

1/2

NOT USED

N406

310

Location Identifier

O 1

1/30

SITUATIONAL

N407

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Patient Event Provider Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

NOT USED

N408

1702

Postal Code-Formatted

X 1

3/20

SEGMENT DETAIL

PRV - PATIENT EVENT PROVIDER INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

1.	P0203 If either PRV02 or PRV03 is present, then the other is required.

Loop:

2010EA — PATIENT EVENT PROVIDER NAME

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when needed to indicate the provider's specialty. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱PE✱PXC✱1223G0001X~


DIAGRAM

PRV

✱

PRV01		1221
Provider Code
M 1	ID	1/3

✱

PRV02		128
Reference Ident Qual
X 1	ID	2/3

✱

PRV03		127
Reference Ident
X 1	AN	1/80

✱

PRV04		156
~~State or~~ ~~Prov Code~~
O 1	ID	2/2

✱

PRV05		C035
~~Provider~~ ~~Spec. Inf.~~
O 1

✱

PRV06		1223
~~Provider~~ ~~Org Code~~
O 1	ID	3/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

PRV01

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Admitting

Assistant Surgeon

Attending

Hospital

Use when the provider is a facility (NM101=FA) or clinic (NM101=G3).

Operating

Ordering

Other Physician

Primary Care Physician

Performing

Referring

REQUIRED

PRV02

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider Taxonomy

REQUIRED

PRV03

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

PRV04

156

State or Province Code

O 1

2/2

NOT USED

PRV05

C035

Provider Specialty Information

O 1

NOT USED

PRV06

1223

Provider Organization Code

O 1

3/3

SEGMENT DETAIL

HL - SERVICE LEVEL

X12 Name:

Hierarchical Level

X12 Purpose:

To identify dependencies among and the content of hierarchically related groups of data segments

X12 Comments:

1.	The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data.
2.	The HL segment defines a top-down/left-right ordered structure.

Loop:

2000F — SERVICE LEVEL
Loop Repeat: >1

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when the Patient Event loop is not valued or when inquiring on authorizations for specific services or procedures. If not required, by this implementation guide, do not send.

TR3 Example:

HL✱6✱5✱SS✱0~


DIAGRAM

✱

HL01		628
Hierarch ID Number
M 1	AN	1/12

✱

HL02		734
Hierarch Parent ID
O 1	AN	1/12

✱

HL03		735
Hierarch Level Code
M 1	ID	1/2

✱

HL04		736
Hierarch Child Code
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HL01

628

Hierarchical ID Number

M 1

1/12

A unique number assigned by the sender to identify a particular data segment in a hierarchical structure

INDUSTRY NAME: Hierarchical Parent ID Number

The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

REQUIRED

HL02

734

Hierarchical Parent ID Number

O 1

1/12

Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.

INDUSTRY NAME: Hierarchical ID Number

REQUIRED

HL03

735

Hierarchical Level Code

M 1

1/2

Code specifying the characteristic of a level in a hierarchical structure

CODE

DEFINITION

Services

REQUIRED

HL04

736

Hierarchical Child Code

O 1

1/1

Code indicating if there are hierarchical child data segments subordinate to the level being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.

CODE

DEFINITION

No Subordinate HL Segment in This Hierarchical Structure.

SEGMENT DETAIL

TRN - SERVICE TRACE NUMBER

X12 Name:

Trace

X12 Purpose:

To uniquely identify a transaction to an application

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Each trace number provided in the TRN segment at this level on the inquiry must be returned by the UMO in the TRN segment at the corresponding level of the response.

2.	If the transaction is routed through a clearinghouse, the clearinghouse may add their own TRN segment. If the transaction passes through multiple clearinghouses, and the second clearinghouse needs to assign their own TRN segment, they must replace the TRN from the first clearinghouse and retain it to be returned in the 278 response. If the second clearinghouse does not need to assign a TRN segment, they should pass all received TRN segments.

TR3 Example:

TRN✱1✱111099✱9012345678✱RADIOLOGY~


DIAGRAM

TRN

✱

TRN01		481
Trace Type Code
M 1	ID	1/2

✱

TRN02		127
Reference Ident
M 1	AN	1/80

✱

TRN03		509
Originating Company ID
O 1	AN	10/10

✱

TRN04		127
Reference Ident
O 1	AN	1/80

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TRN01

481

Trace Type Code

M 1

1/2

Code identifying which transaction is being referenced

CODE

DEFINITION

Current Transaction Trace Numbers

REQUIRED

TRN02

127

Reference Identification

M 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN02 provides unique identification for the transaction.

INDUSTRY NAME: Service Trace Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

REQUIRED

TRN03

509

Originating Company Identifier

O 1

10/10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

SEMANTIC: TRN03 identifies an organization.

INDUSTRY NAME: Trace Assigning Entity Identifier

SITUATIONAL

TRN04

127

Reference Identification

O 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: TRN04 identifies a further subdivision within the organization.

INDUSTRY NAME: Trace Assigning Entity Additional Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

SEGMENT DETAIL

UM - HEALTH CARE SERVICES REVIEW INFORMATION

X12 Name:

Health Care Services Review Information

X12 Purpose:

To specify health care services review information

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Value this segment if you want to limit the inquiry to only referrals or only health care service certifications.

TR3 Example:

UM✱SC✱I✱3~


DIAGRAM

✱

UM01		1525
Request Categ Code
M 1	ID	1/2

✱

UM02		1322
Certificate Type Code
O 1	ID	1/1

✱

UM03		1271
Industry Code
O 1	AN	1/30

✱

UM04		C023
Health Care Serv Loc.
O 1

✱

UM05		C024
~~Related~~ ~~Causes Info~~
O 1

✱

UM06		1338
~~Level of~~ ~~Serv Code~~
O 1	ID	1/3

✱

UM07		1213
~~Current~~ ~~Health Code~~
O 1	ID	1/1

✱

UM08		923
~~Prognosis~~ ~~Code~~
O 1	ID	1/1

✱

UM09		1363
~~Release of~~ ~~Info Code~~
O 1	ID	1/1

✱

UM10		1514
~~Delay~~ ~~Reason Code~~
O 1	ID	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

UM01

1525

Request Category Code

M 1

1/2

Code indicating a type of request

CODE

DEFINITION

Health Services Review

Use when reporting services related to an episode of care.

Specialty Care Review

Use when reporting a referral to a specialty provider.

SITUATIONAL

UM02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

SITUATIONAL RULE: Required when different from the UM02 value at the Patient Event level (Loop 2000E). If not required by this implementation guide, do not send.

CODE

DEFINITION

Appeal - Immediate

Use when reporting appeals of review decisions when the service required was emergency or urgent.

Appeal - Standard

Use when reporting appeals of review decisions when the service required was not emergency or urgent.

Cancel

Extension

Use when requesting additional service units and/or the duration of time for a prior approved service.

Initial

Reconsideration

Use when requesting the UMO to reconsider a previously denied referral or certification.

Renewal

Revised

Use when changing the specifics of a previously submitted request for which services have not been rendered.

SITUATIONAL

UM03

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

SEMANTIC: UM03 is the Service Type (Code Source 958).

INDUSTRY NAME: Service Type Code

Subset 278 of the current version of the Health Care Services Type Codes List represents the codes that are available for use in this element.

SITUATIONAL

UM04

C023

Health Care Service Location Information

O 1

To provide information that identifies the place of service or the type of bill related to the location at which a health care service was rendered

CLICK TO SHOW/HIDE: X12 Composite Syntax Notes

For this service, values at the Service Level override values at the Patient Event Level.

Use of this element assumes that the original health care services review request specified the same facility type. Note that the original health care services review request might have specified a different facility type or expressed the facility as part of the service type in UM03. Use of this element implies that only those authorizations with an exact match on this value are returned by the UMO.

REQUIRED

UM04-01

1331

Facility Code Value

1/3

INDUSTRY NAME: Facility Type Code

Use to indicate a facility code value from the code source referenced in UM04-02.

REQUIRED

UM04-02

1332

Facility Code Qualifier

1/2

Code identifying the type of facility referenced

CODE

DEFINITION

Uniform Billing Claim Form Bill Type

CODE SOURCE 236: Uniform Billing Claim Form Bill Type

Place of Service Codes for Professional or Dental Services

CODE SOURCE 237: Place of Service Codes for Professional Claims

NOT USED

UM04-03

1325

Claim Frequency Type Code

1/1

NOT USED

UM05

C024

Related Causes Information

O 1

NOT USED

UM06

1338

Level of Service Code

O 1

1/3

NOT USED

UM07

1213

Current Health Condition Code

O 1

1/1

NOT USED

UM08

923

Prognosis Code

O 1

1/1

NOT USED

UM09

1363

Release of Information Code

O 1

1/1

NOT USED

UM10

1514

Delay Reason Code

O 1

1/2

SEGMENT DETAIL

HCR - HEALTH CARE SERVICES REVIEW

X12 Name:

Health Care Services Review

X12 Purpose:

To specify the outcome of a health care services review

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	Use of HCR01 (action code) to limit the responses to only those authorizations that match a specific action/status may omit authorizations for which the status has changed. For example, an inquiry on all health care services reviews with a pended status will not return information on a review that has moved from a pended to a final status.

TR3 Example:

HCR✱A1~


DIAGRAM

HCR

✱

HCR01		306
Action Code
M 1	ID	1/2

✱

HCR02		127
~~Reference~~ ~~Ident~~
O 1	AN	1/80

✱

HCR03		1271
~~Industry~~ ~~Code~~
O 5	AN	1/30

✱

HCR04		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HCR01

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Complete

Use when the inquiry is for authorizations with a status of complete. For the UMO, the authorization is complete at the time the claim is received and recorded.

Term Expired

Use when the inquiry is for authorizations with a status of expired.

Certified in total

Not Certified

Pended

Modified

Cancelled

Contact Payer

NOT USED

HCR02

127

Reference Identification

O 1

1/80

NOT USED

HCR03

1271

Industry Code

O 5

1/30

NOT USED

HCR04

1073

Yes/No Condition or Response Code

O 1

1/1

SEGMENT DETAIL

REF - PREVIOUS REVIEW AUTHORIZATION NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	If the UMO locates this certification number and it has not issued a new certification number associated with the same authorization, the UMO must return the same certification identification in HCR02 in the HCR Health Care Services Review segment of the inquiry response. If this certification number is not found or it has been superseded, the UMO must return this number in the REF segment in the corresponding loop of the response.

2.	This is the authorization number assigned by the UMO to the original review outcome associated with this service. This is not the trace number assigned by the requester.

TR3 Example:

REF✱BB✱A123~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Authorization Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Review Authorization Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

REF - PREVIOUS REVIEW ADMINISTRATIVE REFERENCE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

1.	R0203 At least one of REF02 or REF03 is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Notes:


1.	This is the administrative number assigned by the UMO to the original service review outcome. This is not the trace number assigned by the requester.

TR3 Example:

REF✱NT✱123Z~


DIAGRAM

REF

✱

REF01		128
Reference Ident Qual
M 1	ID	2/3

✱

REF02		127
Reference Ident
X 1	AN	1/80

✱

REF03		352
~~Description~~
X 1	AN	1/80

✱

REF04		C040
~~Reference~~ ~~Identifier~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

REF01

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Administrator's Reference Number

REQUIRED

REF02

127

Reference Identification

X 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Previous Administrative Reference Number

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

NOT USED

REF03

352

Description

X 1

1/80

NOT USED

REF04

C040

Reference Identifier

O 1

SEGMENT DETAIL

DTP - SERVICE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when limiting the inquiry to those authorizations for service for a specific service date or service date range. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱472✱D8✱20221030~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

472

Service

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Proposed or Actual Service Date

SEGMENT DETAIL

DTP - CERTIFICATION ISSUE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

DTP✱102✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

102

Issue

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Issue Date

SEGMENT DETAIL

DTP - CERTIFICATION EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

DTP✱036✱D8✱20221002~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

036

Expiration

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Expiration Date

SEGMENT DETAIL

DTP - CERTIFICATION EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

DTP✱007✱RD8✱20221002-20220402~


DIAGRAM

DTP

✱

DTP01		374
Date/Time Qualifier
M 1	ID	3/3

✱

DTP02		1250
Date Time Format Qual
M 1	ID	2/3

✱

DTP03		1251
Date Time Period
M 1	AN	1/35

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DTP01

374

Date/Time Qualifier

M 1

3/3

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

REQUIRED

DTP02

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

REQUIRED

DTP03

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Certification Effective Date

SEGMENT DETAIL

HI - ADDITIONAL SERVICE DESCRIPTION

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

HI✱AAA:422011000124105~


DIAGRAM

✱

HI01		C022
Health Care Code Info.
M 1

✱

HI02		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI03		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI04		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI05		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI06		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI07		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI08		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI09		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI10		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI11		C022
~~Health Care~~ ~~Code Info.~~
O 1

✱

HI12		C022
~~Health Care~~ ~~Code Info.~~
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

HI01

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

CLICK TO SHOW/HIDE: X12 Composite Comments

REQUIRED

HI01-01

1270

Code List Qualifier Code

1/3

Code identifying a specific industry code list

INDUSTRY NAME: Additional Services Description Type Code

CODE

DEFINITION

AAA

SNOMED, Systematized Nomenclature of Medicine

CODE SOURCE 662: SNOMED, Systematized Nomenclature of Medicine

REQUIRED

HI01-02

1271

Industry Code

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Additional Services Description Code

NOT USED

HI01-03

1250

Date Time Period Format Qualifier

2/3

NOT USED

HI01-04

1251

Date Time Period

1/35

NOT USED

HI01-05

782

Monetary Amount

1/18

NOT USED

HI01-06

380

Quantity

1/15

NOT USED

HI01-07

799

Version Identifier

1/30

NOT USED

HI01-08

1271

Industry Code

1/30

NOT USED

HI01-09

1271

Industry Code

1/30

NOT USED

HI01-10

1271

Industry Code

1/30

NOT USED

HI02

C022

Health Care Code Information

O 1

NOT USED

HI03

C022

Health Care Code Information

O 1

NOT USED

HI04

C022

Health Care Code Information

O 1

NOT USED

HI05

C022

Health Care Code Information

O 1

NOT USED

HI06

C022

Health Care Code Information

O 1

NOT USED

HI07

C022

Health Care Code Information

O 1

NOT USED

HI08

C022

Health Care Code Information

O 1

NOT USED

HI09

C022

Health Care Code Information

O 1

NOT USED

HI10

C022

Health Care Code Information

O 1

NOT USED

HI11

C022

Health Care Code Information

O 1

NOT USED

HI12

C022

Health Care Code Information

O 1

SEGMENT DETAIL

SV1 - PROFESSIONAL SERVICE

X12 Name:

Professional Service

X12 Purpose:

To specify the service line item detail for a health care professional

X12 Syntax:

1.	P0304 If either SV103 or SV104 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on authorizations for a specific professional service. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.

TR3 Example:

SV1✱HC:99211:25✱✱UN✱1~


DIAGRAM

SV1

✱

SV101		C003
Comp. Med. Proced. ID
M 1

✱

SV102		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV103		355
Unit/Basis Meas Code
X 1	ID	2/2

✱

SV104		380
Quantity
X 1	R	1/15

✱

SV105		1331
~~Facility~~ ~~Code~~
O 1	AN	1/3

✱

SV106		1271
~~Industry~~ ~~Code~~
O 1	AN	1/30

✱

SV107		1328
~~Diagnosis~~ ~~Code Pointr~~
O 12	N0	1/2

✱

SV108		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV109		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV110		1340
~~Multiple~~ ~~Proc Code~~
O 1	ID	1/2

✱

SV111		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV112		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV113		1364
~~Review~~ ~~Code~~
O 1	ID	1/2

✱

SV114		1341
~~Natl/Local~~ ~~Rev Value~~
O 1	AN	1/2

✱

SV115		1327
~~Copay~~ ~~Status Code~~
O 1	ID	1/1

✱

SV116		1334
~~Healthcare~~ ~~Short Code~~
O 1	ID	1/1

✱

SV117		127
~~Reference~~ ~~Ident~~
O 1	AN	1/80

✱

SV118		116
~~Postal~~ ~~Code~~
O 1	ID	3/15

✱

SV119		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV120		1337
~~Level of~~ ~~Care Code~~
O 1	ID	1/1

✱

SV121		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SV101

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

REQUIRED

SV101-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE 130: Healthcare Common Procedure Coding System

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

Mutually Defined

REQUIRED

SV101-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

NOT USED

SV101-03

1339

Procedure Modifier

2/2

NOT USED

SV101-04

1339

Procedure Modifier

2/2

NOT USED

SV101-05

1339

Procedure Modifier

2/2

NOT USED

SV101-06

1339

Procedure Modifier

2/2

NOT USED

SV101-07

352

Description

1/80

SITUATIONAL

SV101-08

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

NOT USED

SV101-09

1339

Procedure Modifier

2/2

NOT USED

SV101-10

1339

Procedure Modifier

2/2

NOT USED

SV101-11

1339

Procedure Modifier

2/2

NOT USED

SV101-12

1339

Procedure Modifier

2/2

NOT USED

SV102

782

Monetary Amount

O 1

1/18

SITUATIONAL

SV103

355

Unit or Basis for Measurement Code

X 1

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

CODE

DEFINITION

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Minutes

Unit

SITUATIONAL

SV104

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0304

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

NOT USED

SV105

1331

Facility Code Value

O 1

1/3

NOT USED

SV106

1271

Industry Code

O 1

1/30

NOT USED

SV107

1328

Diagnosis Code Pointer

O 12

1/2

NOT USED

SV108

782

Monetary Amount

O 1

1/18

NOT USED

SV109

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV110

1340

Multiple Procedure Code

O 1

1/2

NOT USED

SV111

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV112

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV113

1364

Review Code

O 1

1/2

NOT USED

SV114

1341

National or Local Assigned Review Value

O 1

1/2

NOT USED

SV115

1327

Copay Status Code

O 1

1/1

NOT USED

SV116

1334

Health Care Professional Shortage Area Code

O 1

1/1

NOT USED

SV117

127

Reference Identification

O 1

1/80

NOT USED

SV118

116

Postal Code

O 1

3/15

NOT USED

SV119

782

Monetary Amount

O 1

1/18

NOT USED

SV120

1337

Level of Care Code

O 1

1/1

NOT USED

SV121

1360

Provider Agreement Code

O 1

1/1

SEGMENT DETAIL

SV2 - INSTITUTIONAL SERVICE

X12 Name:

Institutional Service

X12 Purpose:

To specify the service line item detail for a health care institution

X12 Syntax:

1.	R0102 At least one of SV201 or SV202 is required.
2.	P0405 If either SV204 or SV205 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on authorizations for a specific Institutional Service or a specific Revenue Code for the Institutional Service. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.

2.	In cases where a drug is reported, the DRA segment of Service Level Loop ID-2000F can be utilized in place of this segment to further specify drug reporting.

TR3 Example:

SV2✱120✱✱✱DA✱5~

TR3 Example:

SV2✱300✱HC:80019✱✱UN✱1~


DIAGRAM

SV2

✱

SV201		234
Product/ Service ID
X 1	AN	1/80

✱

SV202		C003
Comp. Med. Proced. ID
X 1

✱

SV203		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV204		355
Unit/Basis Meas Code
X 1	ID	2/2

✱

SV205		380
Quantity
X 1	R	1/15

✱

SV206		1371
~~Unit~~ ~~Rate~~
O 1	R	1/10

✱

SV207		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV208		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV209		1345
~~Nurse Home~~ ~~Status Code~~
O 1	ID	1/1

✱

SV210		1337
~~Level of~~ ~~Care Code~~
O 1	ID	1/1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

SITUATIONAL

SV201

234

Product/Service ID

X 1

1/80

Identifying number for a product or service

SEGMENT SYNTAX: R0102

SEMANTIC: SV201 is the revenue code.

SITUATIONAL RULE: Required when inquiring on authorizations for a specific revenue code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Line Revenue Code

See Code Source 132: National Uniform Billing Committee (NUBC) Codes.

SITUATIONAL

SV202

C003

Composite Medical Procedure Identifier

X 1

To identify a medical procedure by its standardized codes and applicable modifiers

SEGMENT SYNTAX: R0102

SITUATIONAL RULE: Required when inquiring on authorizations for a specific procedure code. If not required by this implementation guide, do not send.

REQUIRED

SV202-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

Healthcare Common Procedure Coding System (HCPCS) Codes

Use when reporting HCPCS or CPT codes. AMA's CPT codes are level 1 HCPCS codes.

CODE SOURCE 130: Healthcare Common Procedure Coding System

International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by Format

Mutually Defined

REQUIRED

SV202-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

NOT USED

SV202-03

1339

Procedure Modifier

2/2

NOT USED

SV202-04

1339

Procedure Modifier

2/2

NOT USED

SV202-05

1339

Procedure Modifier

2/2

NOT USED

SV202-06

1339

Procedure Modifier

2/2

NOT USED

SV202-07

352

Description

1/80

SITUATIONAL

SV202-08

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Use SV101-02 to represent the beginning value in a procedure range and this data element to represent the ending value in a range of codes.

NOT USED

SV202-09

1339

Procedure Modifier

2/2

NOT USED

SV202-10

1339

Procedure Modifier

2/2

NOT USED

SV202-11

1339

Procedure Modifier

2/2

NOT USED

SV202-12

1339

Procedure Modifier

2/2

NOT USED

SV203

782

Monetary Amount

O 1

1/18

SITUATIONAL

SV204

355

Unit or Basis for Measurement Code

X 1

2/2

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

CODE

DEFINITION

Days

International Unit

Use when reporting dosage amount. Dosage amount is only used for drug claims when the dosage of the drug is variable within a single NDC number (e.g., blood factors).

Unit

SITUATIONAL

SV205

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: P0405

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the service specified. If not required by this implementation guide, do not send.

INDUSTRY NAME: Service Unit Count

NOT USED

SV206

1371

Unit Rate

O 1

1/10

NOT USED

SV207

782

Monetary Amount

O 1

1/18

NOT USED

SV208

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV209

1345

Nursing Home Residential Status Code

O 1

1/1

NOT USED

SV210

1337

Level of Care Code

O 1

1/1

SEGMENT DETAIL

SV3 - DENTAL SERVICE

X12 Name:

Dental Service

X12 Purpose:

To specify the service line item detail for dental work

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on authorizations for a specific Dental Service. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the Service level is present on the inquiry, it must specify a service type in UM03 or a service or procedure code in SV1, SV2, or SV3.

TR3 Example:

SV3✱AD:D2150✱✱✱✱✱1~


DIAGRAM

SV3

✱

SV301		C003
Comp. Med. Proced. ID
M 1

✱

SV302		782
~~Monetary~~ ~~Amount~~
O 1	R	1/18

✱

SV303		1331
~~Facility~~ ~~Code~~
O 1	AN	1/3

✱

SV304		C006
Oral Cavity Designat.
O 1

✱

SV305		1358
Prosthesis/ Inlay Code
O 1	ID	1/1

✱

SV306		380
Quantity
O 1	R	1/15

✱

SV307		352
~~Description~~
O 1	AN	1/80

✱

SV308		1327
~~Copay~~ ~~Status Code~~
O 1	ID	1/1

✱

SV309		1360
~~Provider~~ ~~Agree Code~~
O 1	ID	1/1

✱

SV310		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

SV311		1328
~~Diagnosis~~ ~~Code Pointr~~
O 12	N0	1/2

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

SV301

C003

Composite Medical Procedure Identifier

M 1

To identify a medical procedure by its standardized codes and applicable modifiers

REQUIRED

SV301-01

235

Product/Service ID Qualifier

2/2

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

American Dental Association Codes

CODE SOURCE 135: American Dental Association

REQUIRED

SV301-02

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Procedure Code

NOT USED

SV301-03

1339

Procedure Modifier

2/2

NOT USED

SV301-04

1339

Procedure Modifier

2/2

NOT USED

SV301-05

1339

Procedure Modifier

2/2

NOT USED

SV301-06

1339

Procedure Modifier

2/2

NOT USED

SV301-07

352

Description

1/80

SITUATIONAL

SV301-08

234

Product/Service ID

1/80

Identifying number for a product or service

INDUSTRY NAME: Product or Service ID

Use SV301-02 to represent the beginning value in the procedure range and this data element to represent the ending value in a range of codes.

NOT USED

SV301-09

1339

Procedure Modifier

2/2

NOT USED

SV301-10

1339

Procedure Modifier

2/2

NOT USED

SV301-11

1339

Procedure Modifier

2/2

NOT USED

SV301-12

1339

Procedure Modifier

2/2

NOT USED

SV302

782

Monetary Amount

O 1

1/18

NOT USED

SV303

1331

Facility Code Value

O 1

1/3

SITUATIONAL

SV304

C006

Oral Cavity Designation

O 1

To identify one or more areas of the oral cavity

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for treatment of an area of the oral cavity. If not required by this implementation guide, do not send.

Do not use this element for inquiring on authorizations for individual teeth. Use the Tooth Information (TOO) segment in this loop to inquire on individual teeth.

The oral cavity area codes are contained in the ISO TC 106 Designation System for Teeth and Areas of the Oral Cavity.

REQUIRED

SV304-01

1361

Oral Cavity Designation Code

1/3

Code Identifying the area of the oral cavity in which service is rendered

CODE SOURCE 135: American Dental Association

NOT USED

SV304-02

1361

Oral Cavity Designation Code

1/3

NOT USED

SV304-03

1361

Oral Cavity Designation Code

1/3

NOT USED

SV304-04

1361

Oral Cavity Designation Code

1/3

NOT USED

SV304-05

1361

Oral Cavity Designation Code

1/3

SITUATIONAL

SV305

1358

Prosthesis, Crown or Inlay Code

O 1

1/1

Code specifying the placement status for the dental work

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for prosthesis, crown, or inlay with the status indicated. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prosthesis, Crown, or Inlay Code

CODE

DEFINITION

Initial Placement

Replacement

SITUATIONAL

SV306

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: SV306 is the number of procedures.

SITUATIONAL RULE: Required when limiting the inquiry to authorizations for a specific number of service units for the procedure specified.

INDUSTRY NAME: Service Unit Count

Number of procedures

NOT USED

SV307

352

Description

O 1

1/80

NOT USED

SV308

1327

Copay Status Code

O 1

1/1

NOT USED

SV309

1360

Provider Agreement Code

O 1

1/1

NOT USED

SV310

1073

Yes/No Condition or Response Code

O 1

1/1

NOT USED

SV311

1328

Diagnosis Code Pointer

O 12

1/2

SEGMENT DETAIL

TOO - TOOTH INFORMATION

X12 Name:

Tooth Identification

X12 Purpose:

To identify a tooth by number and, if applicable, one or more tooth surfaces

X12 Syntax:

1.	P0102 If either TOO01 or TOO02 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on authorizations for a specific tooth number and/or tooth surface related to this procedure line. If not required by this implementation guide, do not send.

TR3 Example:

TOO✱JP✱12✱L:O~


DIAGRAM

TOO

✱

TOO01		1270
Code List Qual Code
X 1	ID	1/3

✱

TOO02		1271
Industry Code
X 1	AN	1/30

✱

TOO03		C005
Tooth Surface
O 1

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

TOO01

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE 135: American Dental Association

REQUIRED

TOO02

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Tooth Code

Code source 135: American Dental Association Codes

SITUATIONAL

TOO03

C005

Tooth Surface

O 1

To identify one or more tooth surface codes

SITUATIONAL RULE: Required when limiting the inquiry to a tooth surface as defined by the procedure code. If not required by this implementation guide, do not send.

REQUIRED

TOO03-01

1369

Tooth Surface Code

1/2

Code identifying the area of the tooth that was treated

CODE

DEFINITION

Buccal

Distal

Facial

Incisal

Lingual

Mesial

Occlusal

NOT USED

TOO03-02

1369

Tooth Surface Code

1/2

NOT USED

TOO03-03

1369

Tooth Surface Code

1/2

NOT USED

TOO03-04

1369

Tooth Surface Code

1/2

NOT USED

TOO03-05

1369

Tooth Surface Code

1/2

SEGMENT DETAIL

DN2 - TOOTH STATUS

X12 Name:

Tooth Summary

X12 Purpose:

To specify the status of individual teeth

X12 Syntax:

1.	P0405 If either DN204 or DN205 is present, then the other is required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

TR3 Example:

DN2✱5✱E✱✱✱✱JP~


DIAGRAM

DN2

✱

DN201		127
Reference Ident
M 1	AN	1/80

✱

DN202		1368
Tooth Status Code
O 1	ID	1/2

✱

DN203		380
~~Quantity~~
O 1	R	1/15

✱

DN204		1250
~~Date Time~~ ~~Format Qual~~
X 1	ID	2/3

✱

DN205		1251
~~Date Time~~ ~~Period~~
X 1	AN	1/35

✱

DN206		1270
Code List Qual Code
M 1	ID	1/3

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DN201

127

Reference Identification

M 1

1/80

1/50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEMANTIC: DN201 is the tooth number.

INDUSTRY NAME: Tooth Number

The Universal National Tooth Designation System must be used to identify tooth numbers for this element. See Code Source 135: American Dental Association.

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

REQUIRED

DN202

1368

Tooth Status Code

O 1

1/2

Code specifying the status of the tooth

CODE

DEFINITION

To Be Extracted

Impacted

Missing

Extracted

NOT USED

DN203

380

Quantity

O 1

1/15

NOT USED

DN204

1250

Date Time Period Format Qualifier

X 1

2/3

NOT USED

DN205

1251

Date Time Period

X 1

1/35

REQUIRED

DN206

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

SEMANTIC: DN206 designates the code set used to identify the tooth in DN201.

CODE

DEFINITION

Universal National Tooth Designation System

CODE SOURCE 135: American Dental Association

SEGMENT DETAIL

DRA - DRUG AUTHORIZATION

X12 Name:

Drug Authorization

X12 Purpose:

To specify a drug for which authorization is being requested

X12 Syntax:

1.	P0405 If either DRA04 or DRA05 is present, then the other is required.
2.	P080910 If either DRA08, DRA09 or DRA10 are present, then the others are required.

Loop:

2000F — SERVICE LEVEL

Segment Repeat:

Usage:

SITUATIONAL

Situational Rule:

Required when inquiring on authorizations for a drug name, drug therapy type or a specific drug. If not required by this implementation guide, do not send.

TR3 Notes:


1.	If the request is for a compound drug, repeat the segment for each ingredient in the compound.

TR3 Example:


DIAGRAM

DRA

✱

DRA01		352
Description
M 2	AN	1/80

✱

DRA02		1322
Certificate Type Code
O 1	ID	1/1

✱

DRA03		C003
Comp. Med. Proced. ID
O 2

✱

DRA04		355
~~Unit/Basis~~ ~~Meas Code~~
X 1	ID	2/2

✱

DRA05		380
~~Quantity~~
X 1	R	1/15

✱

DRA06		933
~~Free-Form~~ ~~Message Txt~~
O 1	AN	1/264

✱

DRA07		1073
~~Yes/No Cond~~ ~~Resp Code~~
O 1	ID	1/1

✱

DRA08		1073
~~Yes/No Cond~~ ~~Resp Code~~
X 1	ID	1/1

✱

DRA09		374
~~Date/Time~~ ~~Qualifier~~
X 1	ID	3/3

✱

DRA10		373
~~Date~~
X 1	DT	8/8

✱

DRA11		933
~~Free-Form~~ ~~Message Txt~~
O 999	AN	1/264

✱

DRA12		380
~~Quantity~~
O 1	R	1/15

✱

DRA13		C060
~~Question~~ ~~and Answer~~
O 999

✱

DRA14		1330
~~Dosage Form~~ ~~Code~~
O 1	ID	2/2

✱

DRA15		933
~~Free-Form~~ ~~Message Txt~~
O 999	AN	1/264

∼

ELEMENT DETAIL

USAGE

REF. DES.

D.E. NUM.

NAME

ATTRIBUTES

REQUIRED

DRA01

352

Description

M 2

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: DRA01 is the drug name. Position of data in the repeating data element conveys no significance.

INDUSTRY NAME: Drug Name

REQUIRED

DRA02

1322

Certification Type Code

O 1

1/1

Code indicating the type of certification

SEMANTIC: DRA02 is the drug therapy type.

INDUSTRY NAME: Drug Therapy Type

CODE

DEFINITION

Extension

Use when this is the extension of the first use of this drug or its therapeutic equivalent as a supplemental therapy for treatment of this condition.

Initial

Use when this is the first use of this drug or its therapeutic equivalent for treatment of this condition.

Renewal

Use when this is for continuation of the use of this drug or its therapeutic equivalent for treatment of this condition.

Revised

Use when this is the first use of this drug or its therapeutic equivalent to replace a previous unsuccessful or non-optimal therapy for treatment of this condition.

SITUATIONAL

DRA03

C003

Composite Medical Procedure Identifier

O 2

To identify a medical procedure by its standardized codes and applicable modifiers

SEMANTIC: DRA03 Position of data in the repeating data element conveys no significance.