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Management Systems Consulting, Inc.

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Updated:05/16/2008

HIPAA 278 Health Care Services Review
Management Systems Consulting, Inc.
VERSION: 1.0 DRAFT

Author: Skip Stein

Notes: In order to protect the security and confidentiality of electronic health information, Congress has passed The Health Insurance Portability and Accountability Act, also known as HIPAA, which was the result of efforts by the Clinton Administration and congressional healthcare reform proponents to reform healthcare in a way that would streamline industry inefficiencies, reduce paperwork, make it easier to detect and prosecute fraud and abuse and enable workers of all professions to change jobs, even if they (or family members) had pre-existing medical conditions.

278
Health Care Services Review - Request for Review
Functional Group=HI

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.

Heading:
Pos Id Segment Name Req Max Use Repeat Notes Usage
010 ST Transaction Set Header M 1
020 BHT Beginning of Hierarchical Transaction M 1
Detail:
Pos Id Segment Name Req Max Use Repeat Notes Usage
Loop ID - 2000A 1
010 HL Utilization Management Organization (UMO) Level M 1
Loop ID - 2010A 1
170 NM1 Utilization Management Organization (UMO) Name O 1
Loop ID - 2000B 1
010 HL Requester Level M 1
Loop ID - 2010B 1
170 NM1 Requester Name O 1
180 REF Requester Supplemental Identification O 8
200 N3 Requester Address O 1
210 N4 Requester City/State/ZIP Code O 1
220 PER Requester Contact Information O 1
240 PRV Requester Provider Information O 1
Loop ID - 2000C 1
010 HL Subscriber Level M 1
070 DTP Accident Date O 1
070 DTP Last Menstrual Period Date O 1
070 DTP Estimated Date of Birth O 1
070 DTP Onset of Current Symptoms or Illness Date O 1
080 HI Subscriber Diagnosis O 1
Loop ID - 2010C 1
170 NM1 Subscriber Name O 1
180 REF Subscriber Supplemental Identification O 9
250 DMG Subscriber Demographic Information O 1
Loop ID - 2000D 1
010 HL Dependent Level O 1
070 DTP Accident Date O 1
070 DTP Last Menstrual Period Date O 1
070 DTP Estimated Date of Birth O 1
070 DTP Onset of Current Symptoms or Illness Date O 1
080 HI Dependent Diagnosis O 1
Loop ID - 2010D 1
170 NM1 Dependent Name O 1
180 REF Dependent Supplemental Identification O 3
250 DMG Dependent Demographic Information O 1
260 INS Dependent Relationship O 1
Loop ID - 2000E >1
010 HL Service Provider Level M 1
160 MSG Message Text O 1
Loop ID - 2010E 3
170 NM1 Service Provider Name O 1
180 REF Service Provider Supplemental Identification O 7
200 N3 Service Provider Address O 1
210 N4 Service Provider City/State/ZIP Code O 1
220 PER Service Provider Contact Information O 1
240 PRV Service Provider Information O 1
Loop ID - 2000F >1
010 HL Service Level M 1
020 TRN Service Trace Number O 2
040 UM Health Care Services Review Information O 1
060 REF Previous Certification Identification O 1
070 DTP Service Date O 1
070 DTP Admission Date O 1
070 DTP Discharge Date O 1
070 DTP Surgery Date O 1
080 HI Procedures O 1
090 HSD Health Care Services Delivery O 1
100 CRC Patient Condition Information O 6
110 CL1 Institutional Claim Code O 1
120 CR1 Ambulance Transport Information O 1
130 CR2 Spinal Manipulation Service Information O 1
140 CR5 Home Oxygen Therapy Information O 1
150 CR6 Home Health Care Information O 1
160 MSG Message Text O 1
280 SE Transaction Set Trailer M 1

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