This Draft Standard for Trial Use contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.
Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.
To indicate the start of a transaction set and to assign a control number
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
To identify dependencies among and the content of hierarchically related groups of data segments
To uniquely identify a transaction to an application
To specify the validity of the request and indicate follow-up action authorized
To specify health care services review information
To specify the outcome of a health care services review
To specify identifying information
To specify any or all of a date, a time, or a time period
To supply information related to the delivery of health care
To specify the delivery pattern of health care services
To supply information on conditions
To supply information specific to hospital claims
To supply information related to the ambulance service rendered to a patient
To supply information related to the chiropractic service rendered to a patient
To supply information regarding certification of medical necessity for home oxygen therapy
To supply information related to the certification of a home health care patient
To identify the type or transmission or both of paperwork or supporting information
To provide a free-form format that allows the transmission of text information
To supply the full name of an individual or organizational entity
To specify identifying information
To specify additional names or those longer than 35 characters in length
To specify the location of the named party
To specify the geographic place of the named party
To identify a person or office to whom administrative communications should be directed
To specify the validity of the request and indicate follow-up action authorized
To specify the identifying characteristics of a provider
To supply demographic information
To provide benefit information on insured entities
To specify any or all of a date, a time, or a time period
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
