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Table of Contents
Introduction .................................................................................................. 5
Modified pages............................................................................................ 7
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1 Introduction to Modified Pages
This document is addenda to the X12N Health Care Services Review — Request
for Review and Response Implementation Guide, originally published May 2000
as 004010X094. As a result of the post publication review process, items were
identified that could be considered impediments to implementation. These items
were passed to the X12N Health Care Work Group that created the original Implementation Guide for their review.
Modifications based on those comments were reflected in a draft version of the
Addenda to the X12N 004010X094 Implementation Guide. Since the X12N
004010X094 Implementation Guide is named for use under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), an NPRM Draft Addenda went
through a Notice of Proposed Rule Making (NPRM) comment process that began
on May 31, 2002. The Addenda reflects changes based on comments received
during the NPRM process and X12N’s own review processes. Only the modifications noted in the NPRM Draft Addenda were considered in the NPRM and X12N
review processes. The Addenda was approved for publication by X12N on October 10, 2002. When using the X12N Health Care Services Review — Request for
Review and Response Implementation Guide, originally published May 2000 as
004010X094 and incorporating the changes identified in the Addenda, the value
used in GS08 must be “004010X094A1".
Each of the changes made to the 004010X094 Implementation Guide has been
annotated with a note in red and a line pointing to the location of the change. For
convenience, the affected 004010X094 Implementation Guide page number is
noted at the bottom of the page. Please note that as a result of insertion or deletion of material Addenda pages may not begin or end at the same place as the
original referenced page. Because of this, Addenda pages are not page for page
replacements and the original pages should be retained.
Changes in the Addenda may have caused changes to the Data Element Dictionary and the Data Element Name Index (Appendix E in the original Implementation Guide), but these changes are not identified in the Addenda. Changes in the
Addenda may also have caused changes to the Examples and the EDI Transmission Examples (Section 4 in the original Implementation Guide), again these are
not identified in the Addenda.
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2.1.3.1
New Sub-section
Added
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Supplemental Service Review Information
Under some circumstances, UMOs may require additional patient information to
determine the medical necessity of the services requested. The 278 supports the
ability to reference paper documentation and to attach electronic documentation
associated with the current health care services review.
The 278 request contains a PWK segment that the requester can use to reference an attachment (paper, electronic, or other medium) associated with the current health care services review. The attachment may be transmitted in a separate X12 functional group (e.g.: 275 Attachment). Refer to Section 2.2.5 for more
information on attachments. Please note that the 275 functionality is not mandated by HIPAA.
2.1.4
Situational Data
Factors such as the type of certification requested, the condition of the patient,
and the individual UMO’s rules for processing certifications make it difficult to
identify a single set of data elements that are required for all types of certifications. To meet the divergent needs of the UMOs and requesters, this guide includes many data elements and segments marked “situational”. Wherever possible, this implementation guide includes notes indicating when to include a situational segment or element. If the segment or element does not have an explanatory note, interpret “situational” to mean “if the information is available and applicable to the certification request or response, include it.”
2.1.5
Service Review Decisions
The UMO must respond to each 278 transaction set received. If the UMO can
process the service review request, the UMO must return a 278 response that
contains an HCR segment at the Service Level (Loop 2000F) in the response to
indicate the status of the service review.
2.1.6
Rejected Transactions
Missing or incorrect application data on the 278 request can cause the UMO to
reject the transaction. For these requests, the UMO must return a 278 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 request
for processing.
2.1.7
Trace Numbers and Transaction Identifiers
This implementation guide provides several methods to enable requesters, clearinghouses, and UMOs to trace the transaction or match the response to the original request. This section describes the segments and data elements that carry
these identifiers.
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2.1.7.1
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BHT03 - Submitter Transaction Identifier
BHT03 identifies the transaction at its highest level. This is particularly useful in
reconciling 278 rejection transactions that may not contain all of the HL Loops.
The receiver of the 278 request transaction (whether it is a clearinghouse or
UMO) must return this identifier in the 278 response BHT03.
2.1.7.2
TRN Segment
The Patient loop (Loop 2000C or Loop 2000D) and the Service loop (Loop
2000F) each contain a TRN segment. This segment enables organizations to
uniquely identify the request. The TRN at the Patient level uniquely identifies the
patient event request. The Service level TRN uniquely identifies the request at
its lowest logical level, the service. Both the requester (provider) and the clearinghouse can add a TRN segment to the request.
The requester (provider) can use this TRN segment to meet several needs. This
enables the requester to accomplish the following:
• uniquely identify this request within the provider’s environment
• uniquely identify each service requested. A single request transaction can contain requests for multiple services represented by multiple occurrences of Loop
2000F. This can generate more than one 278 response from the UMO. The UMO
might certify some of these services immediately and pend others for external review.
• match the associated response to the request
Text
Revised
• 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.
Clearinghouses can provide their own trace numbers in a separate TRN segment
at the Patient level and at the Service level on the request to use for transaction
tracking and matching purposes.
If the TRN segment is used on the request, 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 at the Patient level
(Loop 2000C or Loop 2000D) and Service level (Loop 2000F) on the response.
The UMO cannot use this trace number to identify the certification to the requester.
If the 278 request transaction passes through more than one clearinghouse, the
second (and subsequent) clearinghouse may choose one of the following options:
1. 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.
New Text
Added
8
2. If the second or subsequent clearinghouse does not need to assign their own
TRN segment, they should merely 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
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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.
New Text Added
2.1.7.3
A TRN segment at the patient level (Subscriber or Dependent) is required if
the provider needs to uniquely identify this patient event.
Patient Account Number
The requester (provider) can supply the patient account number as a supplemental identifier for the patient on the request. This value is carried in a REF segment
where REF01 = “EJ” in Loop 2000C - Subscriber or Loop 2000D - Dependent,
whichever is the patient. This information is optional for the requester. However if
the UMO receives the patient account number, they must return it in the 278 response transaction.
2.1.8
Disclaimers
This implementation guide does not support the transmission of general disclaimers as part of the transaction. Trading partners must handle these disclaimers outside of this EDI transaction and should identify procedures for handling these disclaimers in their trading partner agreements.
2.1.9
New Sub-section
Added
Additional Patient Information
Some health care service reviews may require additional information about the
patient that is not supported in the 278 transaction. This implementation guide includes a PWK segment to identify this additional patient information. On the 278
request, the PWK segment enables the requester to reference paper documentation or to attach electronic documentation containing additional patient information associated with the services requested. The requester may provide additional information about the patient at the Patient level and/or specific information
relevant to the service at the Service level.
In the 278 response, the UMO can indicate in the HCR segment that the review
outcome is pended for additional medical necessity information. The UMO can
use the PWK segment on a pended response to identify additional documentation required to complete the health care services review. The UMO can request
information about the patient using the PWK segment at the Patient level and/or
about the service using the PWK segment at the Service level.
In addition to the PWK segment, the UMO can use the HI segment at the Patient
level and/or the HI segment at the Service level of the response to specify codes
that identify the specific information that the UMO requires from the provider to
complete the medical review. On the response, the HI segment supports the use
of codes supplied from the Logical Observation Identifier Names and Codes
(LOINC® ) List. These codes identify high-level health care information groupings,
specific data elements, and associated modifiers.
The LOINC lists are external to ASC X12 standards. See Appendix C, External
Code Sources, for instructions about how to obtain these lists. LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee.
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The Logical Observation Identifier Names and Codes (LOINC®) code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually agreed to by trading partners.
Refer to Section 2.5.5 of this guide for more information on requesting additional
patient information.
2.2
Data Use by Business Use
The 278 is divided into two levels, or tables. See Section 3, Transaction Set, for a
description of the format presented in figure 5, Transaction Set Listing.
Table 1 - Header
POS. # SEG. ID
010
020
ST
BHT
NAME
REQ. DES.
Transaction Set Header
Beginning of Hierarchical Transaction
M
M
MAX USE
LOOP REPEAT
1
1
...
Table 2 - Detail
POS. # SEG. ID
010
020
030
040
050
060
070
080
HL
TRN
AAA
UM
HCR
REF
DTP
HI
NAME
REQ. DES.
LOOP ID - HL
Hierarchical Level
Trace
Request Validation
Health Care Services Review Information
Health Care Services Review
Reference Identification
Date or Time or Period
Health Care Information Codes
MAX USE
LOOP REPEAT
>1
M
O
O
O
O
O
O
O
1
9
9
1
1
9
9
1
...
Figure 5. Transaction Set Listing
The Header level, Table 1, contains the purpose code for the transaction set as
well as date and time stamps. For this implementation guide, BHT02 is either Request (13) or Response (11).
The Detail level, Table 2, contains all data relating to the requested 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:
Loop 2000A contains the UMO
Loop 2000B contains the Requester
Loop 2000C contains the Subscriber
Loop 2000D contains the Dependent
Loop 2000E contains the Service Provider
Loop 2000F contains the Services
The following are sample Table 2 configurations.
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The following example represents a response to a request for multiple services
from multiple providers for a subscriber who is the patient.
UMO (Loop 2000A)
Requester (Loop 2000B)
Subscriber (Loop 2000C)
Service Provider (Loop 2000E)
Service (with Review Outcome Data)(Loop 2000F)
Service Provider (Loop 2000E)
Service (with Review Outcome Data)(Loop 2000F)
For a request transaction, matrix 1, Intended Segment Use for a Request Transaction, identifies the intended segment use by hierarchical level.
PWK Segment
Added
Segment
Position
010
020
030
040
050
060
070
080
090
100
110
120
130
140
150
155
160
170
180
190
200
210
220
230
240
250
260
270
Segment
ID
HL
TRN
AAA
UM
HCR
REF
DTP
HI
HSD
CRC
CL1
CR1
CR2
CR5
CR6
PWK
MSG
NM1
REF
N2
N3
N4
PER
AAA
PRV
DMG
INS
DTP
UMO HL
YES
Service
Requestor Subscriber Dependent Provider
HL
HL
HL
HL
YES
YES
YES
YES
YES
YES
Service
HL
YES
YES
YES
Segment Use Added
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Matrix 1. Intended Segment Use for a Request Transaction
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Matrix 2, Intended Segment Use for a Response Transaction, identifies the intended segment use by hierarchical level for a response transaction.
PWK Segment
Added
Note Added
Segment
Position
010
020
030
040
050
060
070
080
090
100
110
120
130
140
150
155
160
170
180
190
200
210
220
230
240
250
260
270
Segment
ID
HL
TRN
AAA
UM
HCR
REF
DTP
HI
HSD
CRC
CL1
CR1
CR2
CR5
CR6
PWK
MSG
NM1
REF
N2
N3
N4
PER
AAA
PRV
DMG
INS
DTP
UMO HL
YES
YES
Service
Requestor Subscriber Dependent Provider
HL
HL
HL
HL
YES
YES
YES
YES
YES
YES
YES
YES
Segment Use Added
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
*
*
*
YES
*
*
*
YES
YES
YES
YES
YES
YES
YES
Service
HL
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Asterisks Added
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Segment Use Added
Matrix 2. Intended Segment Use for a Response Transaction
Note: An asterisk (*) denotes segments used only for NM1 loops 2010CB and 2010 DB for
Additional Patient Information Contact Name Information
NOTE
For the request/response scope of this implementation guide, the use of UMO, requester, subscriber, dependent, and service provider is consistent and stable
across all transactions. Because the use of these levels is consistent, these levels are described one time. Because the use of the service level differentiates the
transaction’s use, this level is redefined several times to provide the reader with
appropriate information and examples.
2.2.1
Transaction Participants (Loop 2000A, Loop
2000B)
The Loop 2000A and Loop 2000B hierarchical levels are used to convey information about the two primary participants in a health care service review transaction. Figure 6, Information Source and Receiver Levels, presents the Loop 2000A
and Loop 2000B levels.
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PRV Segment
The PRV segment enables the requester to specify the referring provider’s role in
the care of the patient and to indicate the referring provider’s specialty. Use this
segment if the UMO requires this additional information to determine if the referring provider is authorized to request these services for this patient.
2.2.2
Patient (Loop 2000C and Loop 2000D)
Subscriber Loop 2000C and Dependent Loop 2000D identify the patient. Loop
2000C is always required. Loop 2000D is used only when necessary to identify a
patient who is a dependent. Figure 7. Subscriber and Dependent Levels shows
the structure of these loops.
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.
Loop ID Changed
2.2.2.1
Identifying the Patient
The Subscriber Name Loop 2010CA and Dependent Name Loop 2010DA contain
the segments and data elements that hold this patient identification information.
The NM1 and DMG segments contain all the data needed for the requester and
Loop ID Changed
UMO to identify the patient.
Identifying the Subscriber/Patient
In Subscriber Name Loop 2010CA, 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).
Identifying the Dependent
The Dependent Loop (2000D) is required in addition to Loop 2000C if the dependent does not have a unique (different from the subscriber) member ID. The
maximum data elements in Loop 2010DA that can be required by a UMO to identify a dependent are as follows:
Dependent Last Name (NM103)
Loop ID Changed
Dependent First Name (NM104)
Dependent Birth Date (DMG01 and DMG02).
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Table 2 - Subscriber Detail
POS. # SEG. ID
NAME
USAGE
010
020
030
070
070
070
070
080
155
HL
TRN
AAA
DTP
DTP
DTP
DTP
HI
PWK
LOOP ID - 2000C SUBSCRIBER LEVEL
Subscriber Level
Patient Event Tracking Number
Subscriber Request Validation
Accident Date
Last Menstrual Period Date
New Segment
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Subscriber Diagnosis
Additional Patient Information
170
180
230
250
NM1
REF
AAA
DMG
LOOP ID - 2010CA SUBSCRIBER NAME
Subscriber Name
Loop
Subscriber Supplemental Identification
Subscriber Request Validation
Subscriber Demographic Information
NM1
N3
N4
PER
LOOP ID - 2010CB ADDITIONAL PATIENT
New Loop
INFORMATION CONTACT NAME
Additional Patient Information Contact Name
Additional Patient Information Contact Address
Additional Patient Information Contact City/State/Zip Code
Additional Patient Information Contact Information
170
200
210
220
REPEAT
LOOP REPEAT
1
R
S
S
S
Added S
S
S
S
S
1
3
9
1
1
1
1
1
10
R
S
S
S
1
9
9
1
1
ID Changed
1
Added
S
S
S
S
1
1
1
1
Table 2 - Dependent Detail
POS. # SEG. ID
NAME
USAGE
010
020
030
070
070
070
070
080
155
HL
TRN
AAA
DTP
DTP
DTP
DTP
HI
PWK
LOOP ID - 2000D DEPENDENT LEVEL
Dependent Level
Patient Event Tracking Number
Dependent Request Validation
Accident Date
New Segment
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Dependent Diagnosis
Additional Patient Information
170
180
230
250
260
NM1
REF
AAA
DMG
INS
LOOP ID - 2010DA DEPENDENT NAME
Dependent Name
Loop
Dependent Supplemental Identification
Dependent Request Validation
Dependent Demographic Information
Dependent Relationship
NM1
N3
N4
PER
LOOP ID - 2010DB ADDITIONAL PATIENT
INFORMATION CONTACT NAME
New Loop Added
S
Additional Patient Information Contact Name
S
Additional Patient Information Contact Address
S
Additional Patient Information Contact City/State/Zip Code
S
Additional Patient Information Contact Information
170
200
210
220
REPEAT
LOOP REPEAT
1
S
S
S
S
S
S
S
S
S
1
3
9
1
1
1
1
1
10
ID Changed R
1
3
9
1
1
Added
1
S
S
S
S
1
1
1
1
1
Figure 7. Subscriber and Dependent Levels
Subscriber is the Patient
In those cases where the subscriber is the patient or the patient has a unique
identification number (different from the subscriber), only Loop 2000C is used.
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Refer to the segments that appear under Detail - Subscriber in Figure 7. Subscriber and Dependent Levels for a representation of all the segments available
for use.
The following example demonstrates a sufficient way of identifying a patient who
has a unique identification number.
HL*3*2*22*1~
HI*BF:41090~
NM1*IL*1*SMITH*JOE****MI*12345678901~
2.2.2.2.1
New Sub-section
Added
TRN Segment
Use the TRN segment in Loop 2000C only if the subscriber is the patient. This
segment is required if the requester needs to assign a unique tracking number to
the patient event associated with this health care services review. It enables the
requester to:
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional patient information
This TRN segment can occur a maximum of two times per Loop 2000C on the request; once for the provider and once for the clearinghouse. If the TRN segment
is used at this level on the request, the UMO must return it at the same level on
the response.
The TRN segment can occur a maximum of three times per Loop 2000C on the
response. The UMO can use this trace number to reference the request when
asking for additional patient information associated with this health care services
review. UMOs can add their own trace number to the response for tracking purposes. The UMO cannot use this trace number as the health care services review certification number.
2.2.2.2.2
DTP Segments
The DTP segments carry dates relating to the patient’s current condition. This includes accident date, date of onset of current symptoms or illness, date of last
menstrual period, and estimated date of birth. Date diagnosed is associated with
a diagnosis and is contained in the HI segment.
2.2.2.2.3
HI Segment
The HI segment is used to convey diagnosis information. This information is always conveyed at the actual patient HL level. In the previous example, because
the subscriber is the patient, the HI segment appears at Loop 2000C (there
would be no Loop 2000D level). If Loop 2000D were used, this segment would
appear at the Loop 2000D level and not at Loop 2000C.
New Paragraph
Added
OCTOBER 2002
On the response, this HI segment supports the use of codes supplied from the
Logical Observation Identifier Names and Codes (LOINC®) List. The UMO can
use the LOINC codes to request specific information concerning the patient diagnosis or condition that the UMO requires from the provider to complete the medi-
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cal review. Refer to Section 2.2.5 for more information on UMO requests for additional information.
New Paragraph
Added
2.2.2.2.4
New Sub-section
Added
The Logical Observation Identifier Names and Codes (LOINC®) code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually agreed to by trading partners.
PWK Segment
Under some circumstances, the requester may need to provide additional information about the patient that is not supported in the 278. If the subscriber is the
patient, the requester can use this PWK segment to reference paper documentation or to attach electronic documentation containing additional patient information associated with this patient event. This implementation guide supports a
maximum of 10 occurrences of the PWK segment at the Patient (Subscriber or
Dependent) level.
The UMO can use the PWK segment on a pended response to identify additional
documentation required to complete the medical review.
NOTE:
The PWK segment also occurs in the Service loop. Use the PWK segment in the
Service loop if you are requesting multiple services and the additional information
pertains to a specific service and not to all the services requested.
2.2.2.2.5
Loop ID Changed
Loop ID Changed
Loop ID Changed
New Text Added
NM1 Loops
Sub-section Name Changed
The Loop 2010CA NM1 segment is used to convey the subscriber’s name and
identification number. In the preceding example, this is also the name of the patient. This segment should always carry the primary identification number for the
insured. The REF segment in Loop 2010CA should be used only to transmit secondary identification numbers. In the NM1 segment, the identification number
transmitted is the primary member identifier used by the UMO. In most cases the
REF segment contains a supplemental member identifier used by the UMO. However, it can carry a patient identifier, such as a Patient Account Number, used by
the requester. If Loop 2010CA of the request contains a REF segment where
REF01 = “EJ” (Patient Account Number), the UMO must return the same REF
segment on the response.
The Loop 2010CB NM1 and associated N3, N4, and PER segments are used
only on the response. This loop enables the UMO to specify UMO contact information for the additional patient information requested in the UMO’s 278 response. This segment is used in the response at this level only when all of the following conditions are present.
• The subscriber is the patient
• The UMO has requested additional patient information at this level of the response
• The contact information for the additional patient information response differs
from the information provided in the UMO Name Level (Loop 2010A) of the 278
response
New Paragraph
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16
The N3 and N4 segments should be valued only if the response to the request
for additional information must be routed to a specific office location.
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DMG Segment
The DMG segment is used to provide additional information, such as birth date
(DMG01, DMG02), about the patient/subscriber. This segment is used only when
more information is required to identify the patient/subscriber.
2.2.2.2.7
AAA Segment
The AAA segment is used only in a response. The segment is used to identify an
error condition in the original request at the Subscriber level that prohibits processing the original request. Two AAA segments are provided. The first AAA identifies error conditions in the data contained in Loop 2000C. These pertain to invalid
or missing diagnosis codes and dates and patient condition dates. The second
AAA in Loop 2010CA identifies invalid or missing subscriber identification information.
Loop ID Changed
2.2.2.3
Dependent is the Patient
In those cases when the dependent is the patient and has not been issued a
unique identification number, both Loop 2000C and Loop 2000D are required.
Loop 2000C conveys insurance information and Loop 2000D conveys patient-related information. Until the HIPAA Unique Patient Identifier is mandated, if the patient is a dependent of a subscriber and does not have a unique member ID, the
maximum data elements that can be required by a UMO in loop 2010CA and
2010DA to identify a patient are:
Loop 2010CA
Subscriber’s Member ID
Loop ID Changed
Loop 2010DA
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. Figure 7, Subscriber and Dependent Levels, presents Loop
2000C and Loop 2000D.
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~
HI*BF:41090~
NM1*QC*1*SMITH*SEAN~
DMG*D8*19781229*M~
INS*N*19~
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2.2.2.3.1
New Sub-section
Added
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TRN Segment
If Loop 2000D is valued, this TRN segment is required if the requester needs to
assign a unique tracking number to the patient event associated with this health
care services review. It enables the requester to:
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing additional patient information
This TRN segment can occur a maximum of two times per Loop 2000D on the request; once for the provider and once for the clearinghouse. If the TRN segment
is used at this level on the request, the UMO must return it at the same level on
the response.
The TRN segment can occur a maximum of three times per Loop 2000D on the
response. The UMO can use this trace number to reference the request when
asking for additional patient information associated with this health care services
review. UMOs can add their own trace number to the response for tracking purposes. The UMO cannot use this trace number as the health care services review certification number.
2.2.2.3.2
DTP Segments
The DTP segments carry dates relating to the dependent’s current condition. This
includes accident date, date of onset of current symptoms or illness, date of last
menstrual period, and estimated date of birth. Date diagnosed is associated with
a diagnosis and is contained in the HI segment.
2.2.2.3.3
HI Segment
The HI segment is used to convey diagnosis information. This information is always conveyed at the actual patient HL level. Note that in the previous example,
the HI segment appears in Loop 2000D.
New Paragraph
Added
New Paragraph
Added
2.2.2.3.4
New Sub-section
Added
18
On the response, this HI segment supports the use of codes supplied from the
Logical Observation Identifier Names and Codes (LOINC®) List. The UMO can
use the LOINC codes to identify specific information concerning the patient diagnosis or condition that the UMO requires from the provider to complete the medical review. Refer to Section 2.2.5 for more information on UMO requests for additional information.
The Logical Observation Identifier Names and Codes (LOINC®) code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually agreed to by trading partners.
PWK Segment
Under some circumstances, the requester may need to provide additional information about the patient that is not supported in the 278. The requester can use
this PWK segment to reference paper documentation or to attach electronic documentation containing additional patient information associated with this patient
event. This implementation guide supports a maximum of 10 occurrences of the
PWK segment at the Patient (Subscriber or Dependent) level.
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The UMO can use the PWK segment on a pended response to identify additional
documentation required to complete the medical review.
NOTE:
The PWK segment also occurs in the Service loop. Use the PWK segment in the
Service loop if you are requesting multiple services and the additional information
pertains to a specific service and not to all the services requested.
2.2.2.3.5
Loop ID Changed
Loop ID Changed
Loop ID Changed
Loop ID Changed
NM1 Loops
Sub-section Name Changed
Loop ID Changed
The Loop 2010CA NM1 segment is used to convey the subscriber’s name and
identification number. The identification number transferred is the UMO’s identification number for the subscriber. The Loop 2010DA NM1 segment is used to convey the dependent’s name when the dependent is the patient. There is no UMO
primary identifier for the dependent. In most cases the REF segment in Loop
2010DA contains a supplemental identifier used by the UMO. However, it can
carry a patient identifier, such as a Patient Account Number, used by the requester. If Loop 2010DA of the request contains a REF segment where REF01 =
“EJ” (Patient Account Number), the UMO must return the same REF segment on
the response.
In the previous example, Sean Smith is a dependent of Joe Smith whose identification number is 12345678901. Sean Smith is the patient.
New Text
Added
The Loop 2010DB NM1 and associated N3, N4, and PER segments are used
only on the response. This loop enables the UMO to specify UMO contact information for the additional patient information requested at the Dependent level in
the UMO’s 278 response. This segment is used in the response at this level only
when the following conditions are present.
• The UMO has requested additional patient information at this level of the response
• The contact information for the additional patient information response differs
from the information provided in the UMO Name Level (Loop 2010A) of the 278
response
New Paragraph
Added
2.2.2.3.6
The N3 and N4 segments should be valued only if the response to the request
for additional information must be routed to a specific office location.
DMG Segment
The DMG segment is used to provide additional information about the dependent, such as date of birth (DMG01, DMG02). In the previous example, Sean
Smith is a male born on December 29, 1978.
2.2.2.3.7
INS Segment
The INS segment is used only at the Loop 2000D level. The INS segment is used
to convey the relationship of the dependent to the subscriber for identification purposes.
For example:
INS*N*19~
INS01 = N
This value indicates that the insured is a dependent.
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INS02 = 19
This value indicates that the patient is a child of the subscriber.
2.2.2.3.8
AAA Segment
The AAA segment is only used in a response. The AAA segment is used to identify an error condition in the original request at the Dependent level that prohibits
processing the original request. Two AAA segments are provided. The first AAA
identifies error conditions in the data contained in Loop 2000D. These pertain to
invalid or missing diagnosis codes and dates and patient condition dates. The
second AAA in Loop 2010DA identifies invalid or missing dependent identification
information.
Loop ID Changed
2.2.3
Service (Referred-to) Provider (Loop 2000E)
The Loop 2000E hierarchical level is used to identify the health care service
provider (the provider of services). Figure 8, Service Provider Level, presents the
Loop 2000E level.
Table 2 - Detail, Service Provider Level
POS. # SEG. ID
NAME
USAGE
REPEAT
010
160
HL
MSG
LOOP ID - 2000E SERVICE PROVIDER LEVEL
Service Provider Level
Message Text
R
S
1
1
170
180
200
210
220
230
240
NM1
REF
N3
N4
PER
AAA
PRV
LOOP ID - 2010E SERVICE PROVIDER NAME
Service Provider Name
Service Provider Supplemental Identification
Service Provider Address
Service Provider City State ZIP Code
Service Provider Contact Information
Service Provider Request Validation
Service Provider Information
R
S
S
S
S
S
S
1
7
1
1
1
9
1
LOOP REPEAT
>1
3
Figure 8. Service Provider Level
2.2.3.1
MSG Segment
The MSG segment is used on both the request and the response to carry freeform text about the service provider or specialty requested. Normally, this segment is not used.
2.2.3.2
NM1 Segment
The primary identification number for the service provider should appear in the
NM1 segment. The N3 and N4 segments are provided to supply extra information about the service provider. Implementers should use the N3 and N4 segments when there is no commonly known ID for the service provider.
2.2.3.3
PRV Segment
The PRV segment is used in two different ways. First, the segment is used when
referrals are requested for a specialty rather than for a specific service provider.
In this case, only the NM101 and NM102 elements would be used on the preced-
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Table 2 - Service Detail
POS. # SEG. ID
010
020
030
040
050
060
070
070
070
070
070
070
070
080
090
110
120
130
140
150
155
160
170
200
210
220
NAME
USAGE
HL
TRN
AAA
UM
HCR
REF
DTP
DTP
DTP
DTP
DTP
DTP
DTP
HI
HSD
CL1
CR1
CR2
CR5
CR6
PWK
MSG
LOOP ID - 2000F SERVICE LEVEL
Service Level
Service Trace Number
Service Request Validation
Health Care Services Review Information
Health Care Services Review
Previous Certification Identification
Service Date
Admission Date
Discharge Date
Surgery Date
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Procedures
Health Care Services Delivery
Institutional Claim Code
Ambulance Transport Information
Spinal Manipulation Service Information
Home Oxygen Therapy Information
Home Health Care Information
Additional Service Information
New Segment
Message Text
NM1
N3
N4
PER
LOOP ID - 2010F ADDITIONAL SERVICE
New Loop
INFORMATION CONTACT NAME
Additional Service Information Contact Name
Additional Service Information Contact Address
Additional Service Information Contact City/State/Zip Code
Additional Service Information Contact Information
REPEAT
LOOP REPEAT
>1
Added
R
S
S
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
1
3
9
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10
1
1
Added
S
S
S
S
1
1
1
1
Figure 9. Services Level
2.2.4
Services (Loop 2000F)
The Loop 2000F hierarchical level is used to identify the services requested for the
identified patient and to be supplied by the provider identified in Loop 2000E. Loop
2000F is used also to convey the outcome of the service review request in the service
response. Figure 9, Services Level, presents the Service Loop 2000F.
The service level of this transaction allows the inclusion of various patient condition or certification reason indicators. For example, a provider can specify the reason a request may have been delayed and not made within the timeframe required by a UMO.
Factors such as the type of certification request, the condition of the patient, and
the individual UMO’s business rules for processing certifications make it difficult
to identify a single set of data elements that are required for all types of certifications. If the information is available and applicable to the certification request or
response, include it.
Sections 2.2.4.1 Specialty Care Referrals, 2.2.4.2 Health Services Review, and
2.2.4.3 Admission Review provide examples of the segments and elements to in-
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clude in the different types of certification requests. All the examples are based
on the segments as illustrated in figure 9.
2.2.4.1
Specialty Care Referrals
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.
2.2.4.1.1
Initial Request - Office Visit or Service
2.2.4.1.1.1
UM Segment
The UM segment is used to identify the type of health care services request.
UM*SC*I*******Y~
UM01 = SC (Specialty Care Review)
UM02 = I (Initial Request)
UM09 = Y (Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim)
Other data elements in this segment carry additional information about the type
of request and the condition of the patient. Value these additional data elements
only if they provide information relevant to the medical decision.
2.2.4.1.1.2
HSD Segment and HI Segments
The HSD and HI segments are used according to need, either individually or in
conjunction with each other, to describe the service and/or quantity of service being requested.
The HSD segment is used to identify a number of visits. The following example indicates two visits.
HSD*VS*2~
HSD01 = VS (Visits)
HSD02 = 2
The HSD segment can also be used to identify a delivery pattern. The following
example indicates a pattern of three hours per week for four months.
HSD*HS*3*WK**34*4~
HSD01 = HS (Hours)
HSD02 = 3
HSD03 = WK (Per week)
HSD05 = 34 (Month)
HSD06 = 4
In the following example, the initial service requested is for a single office visit for
a consultation at the provider’s office (per HCFA code table).
HL*5*4*SS*0~
TRN*1*111099*9012345678~
UM*SC*I*3*11:B*****Y~
HSD*VS*1~
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The HI segment is used to request that a specific service be performed.
HI*BO:49000::::1~
HI01 - 1 = BO (Health Care Financing Administration Common Procedural
Coding System)
HI01 - 2 = 49000 (Incision, exploratory laparotomy)
HI01 - 6 = 1 (Quantity)
In some cases, it might be convenient to employ both segments. In the following
example, physical therapy is being prescribed at three visits per week for two
months.
HI*BO:97110~
HSD*VS*3*WK**34*2~
New Paragraph
Added
NOTE:
On the response, this HI segment supports the use of codes supplied from the
Logical Observation Identifier Names and Codes (LOINC®) List. The UMO can
use the LOINC codes to request specific information concerning the specific service or procedure that the UMO requires from the provider to complete the medical review. Refer to Section 2.2.5 for more information on UMO requests for additional information.
New Paragraph
Added
The Logical Observation Identifier Names and Codes (LOINC®) code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually agreed to by trading partners.
2.2.4.1.2
Response
A response transaction is used to indicate approval, approval with modification,
or denial of a previous request. Note that the service level segments contained in
a response transaction can vary from the requested level of service. For example, a primary care provider (PCP) may request ten visits to a specialist for a patient. However, the UMO may decide to approve only eight visits (perhaps the
maximum remaining benefit).
The HCR segment is required to provide the results of the review as well as an
associated reference number.
2.2.4.1.2.1
Approval
To approve the specialty care referral request as described previously, the following service level would be returned:
HL*5*4*SS*0~
TRN*2*111099*9012345678~
UM*SC*I*3*11:B~
HCR*A1*0081096G~
HSD*VS*1~
This set of values indicates approval of the request in full. Note that the original
service level details respecting the services requested are returned so that there
is no confusion as to what is being approved.
A reference number 0081096G is supplied and is critical if the provider wishes to
initiate further transactions concerning this service.
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ports a request for certification of services related to a specific treatment or extended care associated with a single patient event.
It does not support a request for approval of multiple treatment plans related to
long-term care or case management. Such complex treatment plans or case management comprise multiple patient events.
The 278 transaction set does not provide support for approval of case management or for tracking individual service review requests within a case.
2.2.4.2.1
Initial Request
2.2.4.2.1.1
UM Segment
The UM segment is used to identify the type of health care services requested.
UM01 = HS (Health Services Review)
UM02 = I (Initial Request)
UM09 = Y (Provider has a Signed Statement Permitting Release of Medical
Billing Data Related to a Claim)
Other data elements in this segment carry additional information about the type
of request and the condition of the patient. Value these additional data elements
only if they provide information that is relevant to the medical decision on this
service review request.
2.2.4.2.1.2
HSD and HI Segments
In a single 2000F service loop, the requester can specify multiple procedures associated with a single treatment. The HI Procedures segment can carry up to 12
procedure codes (HI01 through HI12). All the procedures specified must relate to
one episode of care. The requester can use the HSD segment to specify a delivery pattern for that episode of care to indicate that all the procedures specified
must occur within a single episode, but that episode can be repeated.
Each patient request can handle multiple 2000F loops. This means that the request can handle different services associated with a single patient event.
New Paragraph
Added
NOTE:
On the response, this HI segment supports the use of codes supplied from the
Logical Observation Identifier Names and Codes (LOINC®) List. The UMO can
use the LOINC codes to request specific information concerning the specific service or procedure that the UMO requires from the provider to complete the medical review. Refer to Section 2.2.5 for more information on UMO requests for additional information.
New Paragraph
Added
The Logical Observation Identifier Names and Codes (LOINC®) code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually agreed to by trading partners.
2.2.4.2.1.3
CRC Segments
The CRC segment enables the requester to provide additional patient condition
information that the UMO can use to determine the medical necessity of the services requested. Because this segment does not contain information on the services or treatment requested, it is not used in the response.
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DTP Segment
When identifying a service at a facility (an admission), the DTP segment should
be used to specify the anticipated admission date.
For example:
DTP*435*D8*19980830~
This value indicates that the anticipated admission date is August 30, 1998.
The DTP segment may be used to indicate a range of dates (see the original example). However, when dealing with an admission, the DTP segment should indicate a time period for admission and not the actual start and end date for the hospitalization. The length of stay should not be calculated for the DTP segment values (see HSD).
2.2.4.3.1.3
HSD Segment
The HSD segment is used to specify the length of stay at a facility. For example,
this segment indicates a length of stay of 3 days:
HSD*DY*3~
2.2.4.3.1.4
CL1 Segment
The CL1 segment was used in the example to focus the UMO’s attention on the
admission request. Note the use of the urgent code.
2.2.4.3.2
Response
Admission review response uses are identical to those defined in the specialty
care referrals response section.
2.2.4.3.3
Request for Extension
Admission review request for extension uses are identical to those defined in the
specialty care referrals request for extension section.
2.2.4.3.4
Request for Appeal
Admission review request for appeal uses are identical to those defined in the
specialty care referrals request for appeal section.
2.2.4.4
2.2.4.4.1
Paragraph
Changed
Other Service Line Segments
TRN Segment
The TRN segment enables the requester to assign a unique trace number to
each service (Loop 2000F) requested for a patient. The requester can use this to
trace the transaction or match the response to the request. In situations where
the request contains multiple service loops, the UMO might return a medical decision on some services immediately and pend others for review. In this case, the final decisions on each service may be returned by the UMO at different times.
Use of trace numbers at this level can facilitate matching these different responses to the original request.
The clearinghouse can also add a trace number at this level on the request.
Therefore, this TRN segment can occur a maximum of two times per Loop 2000F
on the request; once for the provider and once for the clearinghouse. If the TRN
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segment is used at this level on the request, the UMO must return it at the same
level on the response.
Paragraph
Changed
The TRN segment can occur a maximum of three times per Loop 2000F on the
response. UMOs can add their own trace numbers to the response for tracking
purposes. The UMO cannot use this trace number as the certification number.
The segment is supplied solely for the convenience of the organization that originated it.
This guide’s authors recommend that requesters use this TRN segment.
2.2.4.4.2
AAA Segment
The AAA and HCR segments are used only in the response. If Loop 2000F is present, either the AAA segment or the HCR segment must be returned. If the UMO
was unable to review the request due to missing or invalid application data at this
level, the UMO must return a 278 response containing a AAA segment at this
level. It identifies the primary error condition in Loop 2000F of the original request
that prohibits processing of the original request.
2.2.4.4.3
HCR Segment
The HCR segment is required if the UMO has reviewed the request. It provides
information on the outcome of the medical review. If the request has been certified in total or certified as modified, the UMO must return a certification number in
this segment. This number identifies the certification to the requester. If the request has been pended, denied, or does not require a medical decision, HCR03
conveys the reason for the non-certification or other status of the request.
2.2.4.4.4
New Sub-section
Added
PWK Segment
Under some circumstances, the requester may need to provide additional information about the patient that is not supported in the 278. The requester can use
this PWK segment to reference paper documentation or to attach electronic documentation containing additional patient information associated with the services
requested in this Service loop. This implementation guide supports a maximum
of 10 occurrences of the PWK segment at the Service level.
The UMO can use the PWK segment on a pended response to identify additional
paper or electronic documentation required to complete the medical review for
the services requested in this loop.
NOTE:
The PWK segment also occurs in the Patient loop (Loop 2000C or Loop 2000D).
Use the PWK segment in the Service loop if you are requesting multiple services
and the additional information pertains to a specific service and not to all the services requested.
2.2.4.4.5
New Sub-section
Added
NM1 Loop
The Loop 2010F NM1 and associated N3, N4, and PER segments are used only
on the response. This loop enables the UMO to specify UMO contact information
for the additional service information requested in the PWK segment(s) in the
same Service level (Loop 2000F) in the UMO’s 278 response. This segment is
used in the response at this level only when all the following conditions are present.
• The UMO has requested additional service information at this level
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• The contact information for the additional service information response differs
from the information provided in the UMO Name Level (Loop 2010A) of the 278
response
The N3 and N4 segments should be valued only if the response to the request
for additional information must be routed to a specific office location.
2.2.5
New Sub-section
Added
2.2.5.1
New Sub-section
Added
2.2.5.2
New Sub-section
Added
2.2.5.2.1
New Sub-section
Added
2.2.5.2.2
New Sub-section
Added
278 Support for Additional Service Review
Information
Section 2 of this guide describes the health care services review information that
the requester and UMO can house within the 278 transaction (ST to SE). It also
describes segments and data elements that enable both the requester and the
UMO to reference additional information associated with a health care services
review that is not contained within the 278. This section provides guidelines for
using these segments and data elements.
Background on the Need Addressed
Under some circumstances, UMOs may require additional patient information to
determine the medical necessity of the services requested. This additional information concerns patient condition or service detail data not supported in the 278
(ST to SE). Depending on the type of health care services review, the requester
might know of additional information required of the UMO at the time the request
is initiated. Or, when the UMO receives the health care services review request,
the UMO may determine that additional information is required to complete the review.
Attaching Additional Information to the 278 Request
The 278 request contains a PWK segment that the requester can use to reference an attachment (paper, electronic, or other medium) associated with the current health care services review. The attachment may be transmitted in a separate X12 functional group (e.g.: 275 Attachment).
PWK Segments
The 278 request supports 10 occurrences of the PWK segment at the Patient
level (Loop 2000C and Loop 2000D) and at the Service level (Loop 2000F). This
enables the requester to attach up to 10 items pertaining to the patient’s condition and/or up to 10 items pertaining to each occurrence of Loop 2000F of the request.
TRN Segments
In addition to the PWK segment, the 278 supports a TRN segment at the Patient
level and at the Service level. The Patient level TRN segment (Patient Event
Tracking Number) is required if the requester needs to assign a unique trace
number to the patient event request. This enables the requester to
• uniquely identify this patient event request
• reconcile the request
• match the response to the request
OCTOBER 2002
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• reference this request in any associated attachments containing additional patient information related to this patient event request.
The Service level TRN Segment (Service Trace Number) is required if the request contains more than one Service level and the requester needs to track
each service level request. This enables the requester to
• uniquely identify each service level request
• reconcile this request with its associated service level response
• reference this request in any associated attachments containing additional information related to this service level request
The UMO can reference these numbers when requesting additional information
pertaining to the patient event or to the services requested.
2.2.5.2.3
Guidelines for Referencing Attachments
1.
The PWK segment is required if the requester has additional documentation
(electronic, paper, or other medium) associated with this health care services review that applies to the patient event and/or the services requested
and the 278 request (ST to SE) does not support this information.
2.
Use the PWK segment at the Patient level if the attachment pertains to this
patient event and/or all the services requested.
3.
Use the PWK segment at the Service level if the information pertains to a
specific service identified in Loop 2000F.
4.
The PWK segment is required to identify attachments that are sent electronically (PWK02 = EL) but are transmitted in another X12 functional group
(e.g., 275) rather than by paper. PWK06 is used to identify the attached
electronic documentation. The number in PWK06 should be referenced in
the electronic attachment.
New Sub-section
Added
Please note that the 275 functionality is not mandated by HIPAA. 275 refers
to the X12N 275 Patient Information Transaction Set. At the time of this writing, there is no adopted standard implementation of the 275 for use with the
278 Health Care Services Review. A draft 275 Additional Information to
Support a Health Care Services Review implementation guide is in progress. The 275 can be used
1) If a new rule names the 275 Additional Information to Support a Health
Care Services Review as a standard for use with this implementation
of the 278.
2) For business uses of the 278 not covered under HIPAA. Use of the
275 should be mutually agreed to by trading partners.
3) To increase the functionality of the 278 request provided that it is
understood that this functionality is not mandated by HIPAA and must
be mutually agreed to by trading partners.
5.
The requester can also use the PWK segment to identify paperwork that is
held at the provider’s office and is available upon request by the UMO (or
appropriate entity).
28 Original Page Number 39 Dated May 2000
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2.2.5.3
New Sub-section
Added
004010X094A1 • 278
HEALTH CARE SERV. REVIEW - REQUEST FOR REVIEW & RESPONSE
Requesting Additional Information on the 278
Response
When responding to a 278 request, the UMO might determine that additional information is required to complete the health care services review. The 278 response enables the UMO to
• indicate that the review outcome is pended for additional medical necessity information
• request this additional information by referencing paperwork that the requester
must complete or by specifying codified information that the requester must provide
• identify a specific contact or destination for the response to this request for additional information
2.2.5.3.1
New Sub-section
Added
BHT Segment
In the BHT segment, BHT02 identifies the purpose of the 278 transaction and
BHT06 identifies the type. A 278 response that contains a request for additional
information must specify the following values:
BHT02 = 11 (Response)
BHT06 = AT (Administrative Action)
2.2.5.3.2
New Sub-section
Added
HCR Segment
If the UMO system can process the service review request, the UMO must return
a 278 response that contains an HCR segment at the Service Level (Loop
2000F) in the response to indicate the status of the service review. The UMO
must value the HCR segment to indicate that the review outcome has been
pended for additional medical necessity information. If the UMO uses the 278 response to request this additional information, the UMO system must value the
HCR segment as follows:
HCR*A4**90~
Where:
HCR01 = “A4" (pended)
HCR03 = “90" (Requested Information Not Received)
2.2.5.3.3
New Sub-section
Added
PWK Segments
The UMO can use the PWK segment on a pended response to identify additional
documentation required to complete the health care services review. The UMO
can request information about the patient using the PWK segment at the Patient
level (Loop 2000C or Loop 2000D) and/or about the service using the PWK segment at the Service level (Loop 2000F). This implementation supports 10 occurrences of the PWK at the Patient level and at the Service level to enable the
UMO to request multiple attachments.
The UMO can use this segment to identify the type of documentation needed
such as forms that the provider must complete. The UMO can also indicate what
medium it has used to send these forms.
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Guidelines for Use of PWK Segments
1.
The PWK segment is required if the UMO is requesting additional documentation (electronic, paper, or other medium) associated with this health care
services review that applies to the patient event and/or the services requested and the UMO does not use LOINC in the HI segments to request
this information.
2.
Paperwork requested at the patient level should apply to the patient event
and/or all the services requested. Use the PWK segment in the appropriate
Service loop if requesting medical necessity information for a specific service.
3.
This PWK segment is required to identify requests for specific data that are
sent electronically (PWK02 = EL) but are transmitted in another X12 functional group rather than by paper or using LOINC in the HI segments of the
response. PWK06 is used to identify the attached electronic questionnaire.
The number in PWK06 should be referenced in the corresponding electronic attachment.
NOTE:
At the time of this writing, there is no adopted standard implementation or
draft implementation of another X12 functional group (such as the 277) for
use with the 278.
4.
2.2.5.3.4
New Sub-section
Added
This PWK segment should not be used if the requester should have provided the information within the 278 request (ST-SE) but failed to do so. In
this case the UMO should use the AAA segments in the 278 response to indicate the data that is missing or invalid.
HI Segments
In addition to or in place of the PWK segment, the UMO can use the HI Diagnosis segment at the Patient level and/or the HI Procedures segment at the Service
level of the pended response to specify codes that identify the specific information that the UMO requires from the provider to complete the medical review. On
the response, the HI segment supports the use of codes supplied from the Logical Observation Identifier Names and Codes (LOINC®) List. These codes identify
high-level health care information groupings, specific data elements, and associated modifiers.
The UMO can use each occurrence of the Health Care Code Information composite (C022) in the HI segment to specify codes that identify the information
needed. In the C022 composite, data elements 1270 and 1271 support the
LOINC. Each HI segment supports 12 occurrences of the C022 composite.
LOINC codes are used to request specific information. LOINC modifier codes are
used to qualify the scope of the request for information. For example, LOINC
code 18657-7 requests the Rehabilitation treatment plan, plan of treatment (narrative). A LOINC modifier code of 18803-7 would qualify the requested information
to include all data of the selected type that represents observations made 30
days or fewer before the starting date of service.
The LOINC lists are external to ASC X12 standards. See Appendix C, External
Code Sources, for instructions about how to obtain these lists. LOINC® is a registered trademark of Regenstrief Institute and the LOINC Committee.
To request additional information using LOINC, value the HI segment as follows:
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HEALTH CARE SERV. REVIEW - REQUEST FOR REVIEW & RESPONSE
HI*LOI:18657-7*LOI:18803-7~
Where “LOI” indicates that the code list used is Logical Observation Identifier
Names and Codes and 18657-7 is the high-level grouping and 18803-7 is the
modifier.
Guidelines for Use of LOI (LOINC) HI Segments
1.
The Logical Observation Identifier Names and Codes (LOINC®) code set
was intended to increase the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when mutually agreed to by trading partners.
2.
Even if the trading partners can accommodate the use of LOINC on the 278
response containing the request for additional information, the UMO cannot
require that the original requester respond to this request using LOINC in
the follow-up response.
3.
LOINC specified in the HI Diagnosis segment at the Patient level should apply to the patient event and/or all the services requested. Use the HI Procedures segment in the appropriate Service loop if using LOINC to request
medical necessity information for specific services or procedures.
4.
If the LOINC request pertains to a specific diagnosis code or procedure
code, place the specific diagnosis or procedure code in the HI C022 composite that precedes the HI C022 composite(s) containing the LOINC. For
example:
HI*BO:490000*LOI:18657-7*LOI:18803-7~
Where BO:49000 identifies the procedure for which additional information is
required.
The Patient level supports only one occurrence of the HI Diagnosis segment. If the original request contained more than six diagnosis codes and
you are using LOINC to request additional information for each diagnosis
code or if you need to specify multiple questions/LOINC codes you cannot
exceed the limit of 12 occurrences of the C022 composite. Similarly, the
Service level supports only one occurrence of the HI Procedures segment.
However, the Service level can repeat. So, you can use multiple occurrences of Loop 2000F, if necessary, to accommodate more than 12 occurrences of the C022 composite.
5.
2.2.5.3.5
New Sub-section
Added
OCTOBER 2002
LOINC should not be used if the requester should have provided the information in the 278 request (ST-SE) but failed to do so. In this case the UMO
should use the AAA segments in the 278 response to indicate the data that
is missing or invalid.
NM1 Loops - Additional Information Contact Name
The 278 response includes NM1 loops to identify the person, office location, or
other destination to route the response to the UMO request for additional information. NM1 Loop 2010CB and NM1 Loop 2010DB identify additional patient information contact name, address, and communication number information and are
intended for use with requests for additional information contained in the PWK or
HI segments at the Patient level. NM1 Loop 2010F identifies additional service information contact name, address, and communication number information for
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use with requests for additional information contained in the PWK or HI segments
at the Service level.
Guidelines for Use of NM1 Loops
1.
Information in this loop overrides information supplied in the UMO Name
NM1 loop (Loop 2010A).
2.
Use this NM1 loop only if
a. the destination for the response to the request for additional patient
information differs from the information specified in the UMO Name
NM1 loop (Loop 2010A).
b. either the PWK segment or HI segment in the associated loop contain
a request for additional information.
New Sub-section
Added
2.2.5.3.6
c. the request for additional information is not transmitted in another X12
functional group where PWK02 = EL.
3.
This NM1 segment is required if this loop is used.
TRN Segments
The UMO must return the trace information supplied with the request transaction
in the response transaction. The UMO must return the Patient Event Tracking
Number and, if used, the Service Trace Number in the appropriate location of the
response. If the UMO has requested additional information at the Patient level or
at the Service level, the UMO should retain the Patient Event Tracking Number or
Service Trace Number from the request.
In addition, UMOs can add a trace number in their own TRN segment at the Patient level (Loop 2000C or Loop 2000D) or at the Service level (Loop 2000F) on
the response.
2.2.5.4
New Sub-section
Added
Responding to a Request for Additional Information
If the 278 response contains a request for additional information, that request
must be specified either in LOINC® or in a separate attachment as specified in
the PWK segment of the response.
In either case, the appropriate reply to a 278 response containing a request for
additional information is not another 278.
The LOINC® code set was intended to increase the functionality of the 278 transaction set and it is not mandated by HIPAA and is only used when mutually
agreed to by trading partners. If LOINC® is used in the UMO response it is assumed that the trading partners have agreed on the appropriate format for the follow-up reply. This guide does not require a provider to respond to this codified request for additional information by using EDI or, specifically, by using another
X12 functional group. However, if the provider wants to respond using an EDI
transaction, the preferred EDI transaction method is a 275. Otherwise it is assumed that the provider will elect a non-EDI method to respond to the request for
additional information. Use of 275 functionality with the 278 is not mandated by
HIPAA and is only used when mutually agreed to by trading partners.
If the PWK segment is used, it indicates that the request for additional information is contained in a non-EDI format such as fax, email, paper mail, or voicemail.
32 Original Page Number 39 Dated May 2000
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It is assumed that the provider will convey the reply to that request for additional
information in a corresponding non-EDI format.
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004010X094A1 • 278
004010X094A1 • 278
JULY
27, 2001
IMPLEMENTATION
278
Health Care Services Review — Request for Review
It is recommended that separate transaction sets be used for different patients.
Table 1 - Header
PAGE #
62
63
POS. # SEG. ID
010
020
ST
BHT
NAME
USAGE
Transaction Set Header
Beginning of Hierarchical Transaction
R
R
REPEAT
LOOP REPEAT
1
1
Table 2 - Utilization Management Organization (UMO) Detail
PAGE #
65
POS. # SEG. ID
010
67
170
NAME
HL
LOOP ID - 2000A UTILIZATION MANAGEMENT
ORGANIZATION (UMO) LEVEL
Utilization Management Organization (UMO) Level
NM1
LOOP ID - 2010A UTILIZATION MANAGEMENT
ORGANIZATION (UMO) NAME
Utilization Management Organization (UMO) Name
USAGE
REPEAT
LOOP REPEAT
1
R
1
1
R
1
Table 2 - Requester Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
70
010
HL
LOOP ID - 2000B REQUESTER LEVEL
Requester Level
R
1
72
75
77
78
80
83
170
180
200
210
220
240
NM1
REF
N3
N4
PER
PRV
LOOP ID - 2010B REQUESTER NAME
Requester Name
Requester Supplemental Identification
Requester Address
Requester City/State/ZIP Code
Requester Contact Information
Requester Provider Information
R
S
S
S
S
S
1
8
1
1
1
1
LOOP REPEAT
1
1
Table 2 - Subscriber Detail
PAGE #
85
87
89
90
91
92
94
34
POS. # SEG. ID
010
020
070
070
070
070
080
HL
TRN
DTP
DTP
DTP
DTP
HI
NAME
LOOP ID - 2000C SUBSCRIBER LEVEL
Subscriber Level
Patient Event Tracking Number
Segment
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Subscriber Diagnosis
Original Page 45 Dated May 2000
USAGE
REPEAT
LOOP REPEAT
1
Added
R
S
S
S
S
S
S
1
2
1
1
1
1
1
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
103
155
PWK
Loop ID Changed
108
111
113
170
180
250
NM1
REF
DMG
004010X094A1 • 278
Segment Added S
Additional Patient Information
LOOP ID - 2010CA SUBSCRIBER NAME
Subscriber Name
Subscriber Supplemental Identification
Subscriber Demographic Information
10
1
R
S
S
1
9
1
Table 2 - Dependent Detail
PAGE #
115
117
119
120
121
122
124
133
POS. # SEG. ID
010
020
070
070
070
070
080
155
HL
TRN
DTP
DTP
DTP
DTP
HI
PWK
Loop ID Changed
138
140
142
144
170
180
250
260
NM1
REF
DMG
INS
NAME
USAGE
REPEAT
LOOP ID - 2000D DEPENDENT LEVEL
Dependent Level
Segment Added
Patient Event Tracking Number
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Dependent Diagnosis
Segment Added
Additional Patient Information
S
S
S
S
S
S
S
S
1
2
1
1
1
1
1
10
LOOP ID - 2010DA DEPENDENT NAME
Dependent Name
Dependent Supplemental Identification
Dependent Demographic Information
Dependent Relationship
R
S
S
S
1
3
1
1
LOOP REPEAT
1
1
Loop Diagram Line Changed
Table 2 - Service Provider Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
147
149
010
160
HL
MSG
LOOP ID - 2000E SERVICE PROVIDER LEVEL
Service Provider Level
Message Text
R
S
1
1
150
153
155
156
158
161
170
180
200
210
220
240
NM1
REF
N3
N4
PER
PRV
LOOP ID - 2010E SERVICE PROVIDER NAME
Service Provider Name
Service Provider Supplemental Identification
Service Provider Address
Service Provider City/State/ZIP Code
Service Provider Contact Information
Service Provider Information
R
S
S
S
S
S
1
7
1
1
1
1
LOOP REPEAT
>1
3
Loop Diagram Line Changed
Table 2 - Service Detail
PAGE #
163
165
167
176
178
180
182
POS. # SEG. ID
010
020
040
060
070
070
070
OCTOBER 2002
HL
TRN
UM
REF
DTP
DTP
DTP
NAME
LOOP ID - 2000F SERVICE LEVEL
Service Level
Service Trace Number
Health Care Services Review Information
Previous Certification Identification
Service Date
Admission Date
Discharge Date
USAGE
REPEAT
LOOP REPEAT
>1
R
S
R
S
S
S
S
1
2
1
1
1
1
1
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004010X094A1 • 278
183
185
204
209
221
223
226
232
237
243
248
249
070
080
090
100
110
120
130
140
150
155
160
280
DTP
HI
HSD
CRC
CL1
CR1
CR2
CR5
CR6
PWK
MSG
SE
Surgery Date
Procedures
Health Care Services Delivery
Patient Condition Information
Institutional Claim Code
Ambulance Transport Information
Spinal Manipulation Service Information
Home Oxygen Therapy Information
Home Health Care Information
Segment
Additional Service Information
Message Text
Transaction Set Trailer
36 Original Page 47 Dated May 2000
Added
S
S
S
S
S
S
S
S
S
S
S
R
1
1
1
6
1
1
1
1
1
10
1
1
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000C • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
004010X094A1
PATIENT
EVENT
TRACKING
• 278
• 2000CNUMBER
• TRN
IMPLEMENTATION
PATIENT EVENT TRACKING NUMBER
Loop: 2000C — SUBSCRIBER LEVEL
Usage: SITUATIONAL
Repeat: 2
Notes:
009
100
6
1. This TRN segment is required if the subscriber is the patient and the
requester needs to assign a unique trace number to the patient event
request. This enables the requester to
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing
additional patient information related to this patient event request.
1
132
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.
2
132
3. Each trace number provided in the TRN segment at this level on the
request must be returned by the UMO in the TRN segment at the
corresponding level of the response.
Example: TRN✽1✽2001042801✽9012345678✽CARDIOLOGY~
009
100
5
STANDARD
TRN Trace
Level: Detail
Position: 020
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To uniquely identify a transaction to an application
DIAGRAM
TRN01
TRN ✽
M
OCTOBER 2002
481
Trace Type
Code
ID
1/2
TRN02
✽
127
Reference
Ident
M
AN 1/30
TRN03
509
✽ Originating ✽
Company ID
O
AN 10/10
TRN04
127
Reference
Ident
O
~
AN 1/30
New Page inserted after page 75 dated May 2000
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004010X094A1 • 278 • 2000C • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
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ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
TRN01
DATA
ELEMENT
481
NAME
ATTRIBUTES
Trace Type Code
M
ID
1/2
AN
1/30
Code identifying which transaction is being referenced
CODE
DEFINITION
1
REQUIRED
TRN02
127
Current Transaction Trace Numbers
Reference Identification
M
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Patient
SEMANTIC:
REQUIRED
TRN03
509
Event Tracking Number
TRN02 provides unique identification for the transaction.
Originating Company Identifier
O
AN
10/10
A unique identifier designating the company initiating the funds transfer
instructions. The first character is one-digit ANSI identification code designation
(ICD) followed by the nine-digit identification number which may be an IRS
employer identification number (EIN), data universal numbering system (DUNS),
or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned
number is 9
INDUSTRY: Trace
SEMANTIC:
Assigning Entity Identifier
TRN03 identifies an organization.
1323
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.
1324
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
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Trace
SEMANTIC:
1325
38
Assigning Entity Additional Identifier
TRN04 identifies a further subdivision within the organization.
Use this information if necessary to further identify a specific
component, such as a specific division or group, of the company
identified in the previous data element (TRN03).
New Page inserted after page 75 dated May 2000
OCTOBER 2002
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New Segment Added
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2000C
• PWK
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
Loop: 2000C — SUBSCRIBER LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
009
100
9
1. This PWK segment is used only if the subscriber is the patient.
2. This PWK segment is required if the requester has additional
documentation (electronic, paper, or other medium) associated with
this health care services review that applies to the patient event
and/or all the services requested. This PWK segment should not be
used if
010
100
0
a. the 278 request (ST-SE) supports this information in its segments
and data elements, or
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to a specific service identified in Loop
2000F and not to all the services requested.
010
100
1
3. This PWK segment is required to identify attachments that are sent
electronically (PWK02 = EL) but are transmitted in another X12
functional group rather than by paper or other medium. PWK06 is
used to identify the attached electronic documentation. The number in
PWK06 would be referenced in the electronic attachment.
010
100
2
4. The requester can also use this PWK segment to identify paperwork that
is held at the provider’s office and is available upon request by the UMO
(or appropriate entity). Use code AA in PWK02 to convey this specific
use of the PWK segment. See code note under PWK02, code AA.
Refer to Section 2.2.5 for more information on using this PWK
segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
009
100
8
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
OCTOBER 2002
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
New Page inserted after page 88 dated May 2000
39
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
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New Segment Added
DIAGRAM
PWK01
PWK
755
PWK02
756
PWK03
757
PWK04
Report
Report
✽ Report Type ✽
✽
✽
Copies Need
Code
Transm Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
O
ID
PWK05
✽
2/3
66
ID Code
Qualifier
X
ID
PWK06
✽
1/2
67
ID
Code
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
ID
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
Report Type Code
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000103
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000104
59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
40 New Page inserted after page 88 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000105
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000106
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000107
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000108
OCTOBER 2002
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
New Page inserted after page 88 dated May 2000
41
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
REQUIRED
PWK02
756
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
AA
Transmission Code
DEFINITION
Available on Request at Provider Site
This means that the paperwork is not being sent
with the request at this time. Instead, it is available
to the UMO (or appropriate entity) on request.
1000109
BM
By Mail
EL
Electronically Only
Use to indicate that the attachment is being
transmitted in a separate X12 functional group.
1000110
EM
42 New Page inserted after page 88 dated May 2000
E-Mail
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
FX
By Fax
VO
Voice
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
Use this for voicemail or phone communication.
1000111
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “AA”
or “VO”. The requester can use it when PWK02 equals “AA” if the
requester wants to send a document control number for an
attachment remaining at the Provider’s office.
1000112
CODE
DEFINITION
AC
SITUATIONAL
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
P0506
Required if PWK02 equals BM, EL, EM or FX.
1000113
SITUATIONAL
Control Number
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
Description
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000114
NOT USED
PWK08
C002
ACTIONS INDICATED
O
NOT USED
PWK09
1525
Request Category Code
O
OCTOBER 2002
ID
1/2
New Page inserted after page 88 dated May 2000
43
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
INDIVIDUAL OR ORGANIZATIONAL NAME
004010X094A1
SUBSCRIBER NAME
• 278 • 2010CA • NM1
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
SUBSCRIBER NAME
Loop: 2010CA — SUBSCRIBER NAME Repeat: 1
Usage: REQUIRED
Repeat: 1
Notes:
0
148
1. Use this segment to convey the name and identification number of the
subscriber (who may also be the patient).
5
126
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)
1
142
3. Refer to Section 2.2.2.1 Identifying the Patient for specific information
on how to identify an individual to a UMO.
Example: NM1✽IL✽1✽SMITH✽JOE✽✽✽✽MI✽12345678901~
2
142
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
DIAGRAM
NM101
NM1
M
ID
NM107
O
NM102
✽
2/3
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
44
98
Entity ID
Code
✽
ID
O
66
NM109
ID Code
Qualifier
X
ID
Original Page 89 Dated May 2000
1/2
1035
Name Last/
Org Name
1/1
NM108
✽
NM103
✽
AN 1/35
X
AN 2/80
ID
2/2
1037
Name
Middle
O
706
Entity
Relat Code
X
NM105
✽
AN 1/25
NM110
✽
1036
Name
First
O
67
ID
Code
✽
NM104
✽
AN 1/25
NM111
O
ID
1038
Name
Prefix
O
AN 1/10
98
Entity ID
Code
✽
NM106
✽
~
2/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
Loop ID Changed
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
IL
REQUIRED
NM102
1065
DEFINITION
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
O
AN
1/35
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
SITUATIONAL
NM103
1035
DEFINITION
Person
Name Last or Organization Name
Individual last name or organizational name
INDUSTRY: Subscriber
Use if name information is needed to identify the subscriber.
1266
SITUATIONAL
Last Name
NM104
1036
Name First
O
AN
1/25
Individual first name
INDUSTRY: Subscriber
Use if name information is needed to identify the subscriber.
1266
SITUATIONAL
First Name
NM105
1037
Name Middle
O
AN
1/25
Individual middle name or initial
INDUSTRY: Subscriber
Middle Name
Use if name information is needed to identify the subscriber and
middle name/initial of the subscriber is known.
1267
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Subscriber
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1223
REQUIRED
Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0809
CODE
MI
1475
OCTOBER 2002
DEFINITION
Member Identification Number
The code MI is intended to be the subscriber’s
identification number as assigned by the payer.
Payers use different terminology to convey the
same number. Use MI - Member Identification
Number to convey the following terms:
Insured’s ID, Subscriber’s ID, Health Insurance
Claim Number (HIC), etc.
Original Page 90 Dated May 2000
45
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
1268
REQUIRED
Loop ID Changed
NM109
67
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ZZ
Mutually Defined
The value “ZZ”, when used in this data element,
shall be defined as “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.
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Subscriber
ALIAS: Subscriber
SYNTAX:
Primary Identifier
Member Number
P0809
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
46
Original Page 91 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010CA • REF
SUBSCRIBER SUPPLEMENTAL IDENTIFICATION
004010X094A1SUPPLEMENTAL
SUBSCRIBER
REF
• 278 • 2010CA • IDENTIFICATION
Loop ID Changed
IMPLEMENTATION
SUBSCRIBER SUPPLEMENTAL
IDENTIFICATION
Loop: 2010CA — SUBSCRIBER NAME
Loop ID Changed
Usage: SITUATIONAL
Repeat: 9
Notes:
1
127
1. Use this segment when needed to provide a supplemental identifier
for the subscriber. The primary identifier is the Member Identification
Number in the NM1 segment.
2
127
2. Health Insurance Claim (HIC) Number or Medicaid Recipient
Identification Numbers are to be provided in the NM1 segment as a
Member Identification Number when it is the primary number a UMO
knows a member by (such as for Medicare or Medicaid). Do not use
this segment for the Health Insurance Claim (HIC) Number or Medicaid
Recipient Identification Number unless they are different from the
Member Identification Number provided in the NM1 segment.
3
142
3. If the requester values this segment with the Patient Account Number
(REF01="EJ") on the request, the UMO must return the same value in
this segment on the response.
Example: REF✽SY✽123456789~
7
102
STANDARD
REF Reference Identification
Level: Detail
Position: 180
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
M
OCTOBER 2002
128
Reference
Ident Qual
ID
2/3
REF02
127
Reference
Ident
✽
X
AN 1/30
REF03
✽
352
Description
X
AN 1/80
REF04
✽
C040
Reference
Identifier
~
O
Original Page 92 Dated May 2000
47
004010X094A1 • 278 • 2010CA • REF
SUBSCRIBER SUPPLEMENTAL IDENTIFICATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
REF01
DATA
ELEMENT
128
NAME
ATTRIBUTES
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
1L
Group or Policy Number
Use this code only if you cannot determine if the
number is a Group Number (6P) or a Policy Number
(IG).
1476
1W
Member Identification Number
Do not use if NM108 = MI.
1269
6P
Group Number
A6
Employee Identification Number
EJ
Patient Account Number
Use this code only if the subscriber is the patient.
1176
F6
Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the
subscriber’s HIC number is the primary identifier for
his or her coverage. Use this code only in a REF
segment when the payer has a different member
number, and there is also a need to pass the
subscriber’s HIC number. This might occur in a
Medicare HMO situation.
1177
HJ
Identity Card Number
Use this code when the Identity Card Number differs
from the Member Identification Number. This is
particularly prevalent in the Medicaid environment.
1270
IG
Insurance Policy Number
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number
SY
Social Security Number
Use this code only if the Social Security Number
was not used by the payer as its primary method of
identifying the subscriber. The social security
number may not be used for Medicare.
1000085
REQUIRED
DEFINITION
REF02
127
Reference Identification
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Subscriber
SYNTAX:
Supplemental Identifier
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
48
Original Page 93 Dated May 2000
AN
1/80
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010CA • DMG
SUBSCRIBER DEMOGRAPHIC INFORMATION
Loop ID Changed
004010X094A1DEMOGRAPHIC
SUBSCRIBER
DMG
• 278 • 2010CA •INFORMATION
IMPLEMENTATION
SUBSCRIBER DEMOGRAPHIC INFORMATION
Loop ID Changed
Loop: 2010CA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
4
127
1. Required only when birth date and/or gender information is needed to
identify the subscriber/patient.
2. Refer to Section 2.2.2.1 Identifying the Patient for specific information
on how to identify an individual to a UMO.
3
127
Example: DMG✽D8✽19580322✽M~
8
102
STANDARD
DMG Demographic Information
Level: Detail
Position: 250
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
Syntax:
1. P0102
If either DMG01 or DMG02 is present, then the other is required.
DIAGRAM
DMG01
DMG ✽
1250
Date Time
format Qual
X
ID
O
ID
✽
X
26
DMG08
Country
Code
2/3
✽
1251
Date Time
Period
2/3
DMG07
✽
DMG02
ID
1068
Gender
Code
✽
AN 1/35
O
659
Basis of
Verif Code
O
DMG03
ID
DMG09
1/2
O
R
1067
DMG05
1109
DMG06
1066
Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1
O
ID
1/1
O
ID
1/1
O
ID
1/2
380
Quantity
✽
DMG04
~
1/15
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
DMG01
DATA
ELEMENT
1250
NAME
ATTRIBUTES
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
SYNTAX:
P0102
CODE
D8
OCTOBER 2002
DEFINITION
Date Expressed in Format CCYYMMDD
Original Page 94 Dated May 2000
49
004010X094A1 • 278 • 2010CA • DMG
SUBSCRIBER DEMOGRAPHIC INFORMATION
REQUIRED
DMG02
1251
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
Loop ID Changed
INDUSTRY: Subscriber
SYNTAX:
P0102
SEMANTIC:
SITUATIONAL
DMG03
1068
Birth Date
DMG02 is the date of birth.
Gender Code
O
ID
1/1
Code indicating the sex of the individual
INDUSTRY: Subscriber
Gender Code
Use if gender is needed to identify the subscriber.
1276
CODE
DEFINITION
F
Female
M
Male
U
Unknown
NOT USED
DMG04
1067
Marital Status Code
O
ID
1/1
NOT USED
DMG05
1109
Race or Ethnicity Code
O
ID
1/1
NOT USED
DMG06
1066
Citizenship Status Code
O
ID
1/2
NOT USED
DMG07
26
Country Code
O
ID
2/3
NOT USED
DMG08
659
Basis of Verification Code
O
ID
1/2
NOT USED
DMG09
380
Quantity
O
R
1/15
50
Original Page 95 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000D • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
004010X094A1
PATIENT
EVENT
TRACKING
• 278
• 2000DNUMBER
• TRN
IMPLEMENTATION
PATIENT EVENT TRACKING NUMBER
Loop: 2000D — DEPENDENT LEVEL
Usage: SITUATIONAL
Repeat: 2
Notes:
009
100
6
1. This TRN segment is required if the dependent is the patient and the
requester needs to assign a unique trace number to the patient event
request. This enables the requester to
• uniquely identify this patient event request
• trace the request
• match the response to the request
• reference this request in any associated attachments containing
additional patient information related to this patient event request.
1
132
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.
2
132
3. Each trace number provided in the TRN segment at this level on the
request must be returned by the UMO in the TRN segment at the
corresponding level of the response.
Example: TRN✽1✽2001042801✽9012345678✽CARDIOLOGY~
009
100
5
STANDARD
TRN Trace
Level: Detail
Position: 020
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To uniquely identify a transaction to an application
DIAGRAM
TRN01
TRN ✽
M
OCTOBER 2002
481
Trace Type
Code
ID
1/2
TRN02
✽
127
Reference
Ident
M
AN 1/30
TRN03
509
✽ Originating ✽
Company ID
O
AN 10/10
TRN04
127
Reference
Ident
O
~
AN 1/30
New Page inserted after page 97 dated May 2000
51
004010X094A1 • 278 • 2000D • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
TRN01
DATA
ELEMENT
481
NAME
ATTRIBUTES
Trace Type Code
M
ID
1/2
AN
1/30
Code identifying which transaction is being referenced
CODE
DEFINITION
1
REQUIRED
TRN02
127
Current Transaction Trace Numbers
Reference Identification
M
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Patient
SEMANTIC:
REQUIRED
TRN03
509
Event Tracking Number
TRN02 provides unique identification for the transaction.
Originating Company Identifier
O
AN
10/10
A unique identifier designating the company initiating the funds transfer
instructions. The first character is one-digit ANSI identification code designation
(ICD) followed by the nine-digit identification number which may be an IRS
employer identification number (EIN), data universal numbering system (DUNS),
or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned
number is 9
INDUSTRY: Trace
SEMANTIC:
Assigning Entity Identifier
TRN03 identifies an organization.
1323
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.
1324
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
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Trace
SEMANTIC:
1325
Assigning Entity Additional Identifier
TRN04 identifies a further subdivision within the organization.
Use this information if necessary to further identify a specific
component, such as a specific division or group, of the company
identified in the previous data element (TRN03).
52 New Page inserted after page 97 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2000D
• PWK
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
Loop: 2000D — DEPENDENT LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
010
100
0
1. This PWK segment is required if the requester has additional
documentation (electronic, paper, or other medium) associated with
this health care services review that applies to the patient event
and/or all the services requested. This PWK segment should not be
used if
a. the 278 request (ST-SE) supports this information in its segments
and data elements, or
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to a specific service identified in Loop
2000F and not to all the services requested.
010
100
1
2. This PWK segment is required to identify attachments that are sent
electronically (PWK02 = EL) but are transmitted in another X12
functional group rather than by paper or other medium. PWK06 is
used to identify the attached electronic documentation. The number in
PWK06 would be referenced in the electronic attachment.
010
100
2
3. The requester can also use this PWK segment to identify paperwork
that is held at the provider’s office and is available upon request by
the UMO (or appropriate entity). Use code AA in PWK02 to convey this
specific use of the PWK segment. See code note under PWK02, code
AA.
Refer to Section 2.2.5 for more information on using this PWK
segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
009
100
8
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
OCTOBER 2002
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
New Page inserted after page 111 dated May 2000
53
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
DIAGRAM
PWK01
PWK
755
PWK02
756
PWK03
757
PWK04
Report
Report
✽ Report Type ✽
✽
✽
Copies Need
Code
Transm Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
ID
O
ID
PWK05
✽
2/3
66
ID Code
Qualifier
X
ID
PWK06
✽
1/2
67
ID
Code
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
Report Type Code
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000103
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000104
59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
54 New Page inserted after page 111 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000105
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000106
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000107
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000108
OCTOBER 2002
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
New Page inserted after page 111 dated May 2000
55
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
REQUIRED
PWK02
756
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
AA
Transmission Code
DEFINITION
Available on Request at Provider Site
This means that the paperwork is not being sent
with the request at this time. Instead, it is available
to the UMO (or appropriate entity) on request.
1000109
BM
By Mail
EL
Electronically Only
Use to indicate that the attachment is being
transmitted in a separate X12 functional group.
1000110
EM
E-Mail
56 New Page inserted after page 111 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
FX
By Fax
VO
Voice
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
Use this for voicemail or phone communication.
1000111
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “AA”
or “VO”. The requester can use it when PWK02 equals “AA” if the
requester wants to send a document control number for an
attachment remaining at the Provider’s office.
1000112
CODE
DEFINITION
AC
SITUATIONAL
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
P0506
Required if PWK02 equals BM, EL, EM or FX.
1000113
SITUATIONAL
Control Number
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
Description
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000114
NOT USED
PWK08
C002
ACTIONS INDICATED
O
NOT USED
PWK09
1525
Request Category Code
O
OCTOBER 2002
ID
1/2
New Page inserted after page 111 dated May 2000
57
004010X094A1 • 278 • 2010DA • NM1
DEPENDENT NAME
004010X094A1NAME
DEPENDENT
• 278 • 2010DA • NM1
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
DEPENDENT NAME
Loop: 2010DA — DEPENDENT NAME Repeat: 1
Usage: REQUIRED
Repeat: 1
Notes:
8
145
1. Use this segment to convey the name of the dependent who is the
patient.
6
128
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)
1
142
3. Refer to Section 2.2.2.1 Identifying the Patient for specific information
on how to identify an individual to a UMO.
Example: NM1✽QC✽1✽SMITH✽MARY~
4
142
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
DIAGRAM
NM101
NM1 ✽
M
ID
NM107
O
NM102
✽
2/3
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
58
98
Entity ID
Code
ID
ID
1/2
Original Page 112 Dated May 2000
1035
Name Last/
Org Name
O
66
ID Code
Qualifier
X
✽
1/1
NM108
✽
NM103
X
O
67
ID
Code
AN 2/80
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
1036
Name
First
✽
AN 1/35
NM109
✽
NM104
AN 1/25
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
NM111
✽
NM106
~
2/3
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010DA • NM1
DEPENDENT NAME
Loop ID Changed
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
QC
REQUIRED
NM102
1065
DEFINITION
Patient
Entity Type Qualifier
M
ID
1/1
O
AN
1/35
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
SITUATIONAL
NM103
1035
DEFINITION
Person
Name Last or Organization Name
Individual last name or organizational name
INDUSTRY: Dependent
Use if name information is needed to identify the dependent.
1399
SITUATIONAL
Last Name
NM104
1036
Name First
O
AN
1/25
Individual first name
INDUSTRY: Dependent
Use if name information is needed to identify the dependent.
1288
SITUATIONAL
First Name
NM105
1037
Name Middle
O
AN
1/25
Individual middle name or initial
INDUSTRY: Dependent
Middle Name
Use if name information is needed to identify the dependent and
the middle name/initial of the dependent is known.
1287
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Dependent
Name Suffix
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1223
NOT USED
NM108
66
Identification Code Qualifier
X
ID
1/2
NOT USED
NM109
67
Identification Code
X
AN
2/80
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
OCTOBER 2002
Original Page 113 Dated May 2000
59
004010X094A1 • 278 • 2010DA • REF
DEPENDENT SUPPLEMENTAL IDENTIFICATION
004010X094A1SUPPLEMENTAL
DEPENDENT
REF
• 278 • 2010DA •IDENTIFICATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
DEPENDENT SUPPLEMENTAL
IDENTIFICATION
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 3
Notes:
9
128
1. Use this segment when necessary to provide supplemental identifiers
for the dependent.
0
129
2. Use the Subscriber Supplemental Identifier (REF) segment in Loop
2010C for supplemental identifiers related to the subscriber’s policy
or group number.
7
139
3. If the requester values this segment with the Patient Account Number
( REF01 = “EJ”) on the request, the UMO must return the same value
in this segment on the response.
Example: REF✽SY✽123456789~
1
103
STANDARD
REF Reference Identification
Level: Detail
Position: 180
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
128
Reference
Ident Qual
M
ID
2/3
REF02
127
Reference
Ident
✽
X
REF03
✽
AN 1/30
352
Description
X
AN 1/80
REF04
C040
Reference
Identifier
✽
~
O
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
REF01
DATA
ELEMENT
128
NAME
ATTRIBUTES
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
60
Original Page 114 Dated May 2000
DEFINITION
A6
Employee Identification Number
EJ
Patient Account Number
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010DA • REF
DEPENDENT SUPPLEMENTAL IDENTIFICATION
Loop ID Changed
SY
Social Security Number
The social security number may not be used for
Medicare.
1283
REQUIRED
REF02
127
Reference Identification
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Dependent
SYNTAX:
Supplemental Identifier
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
1/80
Original Page 115 Dated May 2000
61
004010X094A1 • 278 • 2010DA • DMG
DEPENDENT DEMOGRAPHIC INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
004010X094A1DEMOGRAPHIC
DEPENDENT
• 278 • 2010DAINFORMATION
• DMG
IMPLEMENTATION
DEPENDENT DEMOGRAPHIC INFORMATION
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
2
129
1. Required only when birth date and/or gender information is needed to
identify the dependent.
2. Refer to Section 2.2.2.1 Identifying the Patient for specific information
on how to identify an individual to a UMO.
3
127
Example: DMG✽D8✽19580322✽M~
2
103
STANDARD
DMG Demographic Information
Level: Detail
Position: 250
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
Syntax:
1. P0102
If either DMG01 or DMG02 is present, then the other is required.
DIAGRAM
DMG01
DMG ✽
1250
Date Time
format Qual
X
ID
O
ID
✽
X
26
DMG08
Country
Code
2/3
✽
1251
Date Time
Period
2/3
DMG07
✽
DMG02
ID
1068
Gender
Code
✽
AN 1/35
O
659
Basis of
Verif Code
O
DMG03
ID
DMG09
1/2
O
R
1067
DMG05
1109
DMG06
1066
Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1
O
ID
1/1
O
ID
1/1
O
ID
1/2
380
Quantity
✽
DMG04
~
1/15
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
DMG01
DATA
ELEMENT
1250
NAME
ATTRIBUTES
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
SYNTAX:
P0102
CODE
D8
62
Original Page 116 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
DMG02
1251
004010X094A1 • 278 • 2010DA • DMG
DEPENDENT DEMOGRAPHIC INFORMATION
Loop ID Changed
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Dependent
SYNTAX:
P0102
SEMANTIC:
SITUATIONAL
DMG03
1068
Birth Date
DMG02 is the date of birth.
Gender Code
O
ID
1/1
Code indicating the sex of the individual
INDUSTRY: Dependent
Gender Code
Use if gender is needed to identify the Dependent.
1400
CODE
DEFINITION
F
Female
M
Male
U
Unknown
NOT USED
DMG04
1067
Marital Status Code
O
ID
1/1
NOT USED
DMG05
1109
Race or Ethnicity Code
O
ID
1/1
NOT USED
DMG06
1066
Citizenship Status Code
O
ID
1/2
NOT USED
DMG07
26
Country Code
O
ID
2/3
NOT USED
DMG08
659
Basis of Verification Code
O
ID
1/2
NOT USED
DMG09
380
Quantity
O
R
1/15
OCTOBER 2002
Original Page 117 Dated May 2000
63
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
004010X094A1RELATIONSHIP
DEPENDENT
• 278 • 2010DA • INS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
DEPENDENT RELATIONSHIP
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
1
129
1. Use this segment to convey information on the relationship of the
dependent to the insured.
2. Required when necessary to further identify the patient. Examples
include identifying a patient in a multiple birth or differentiating
dependents with the same name.
3
129
Example: INS✽N✽19~
3
103
STANDARD
INS Insured Benefit
Level: Detail
Position: 260
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To provide benefit information on insured entities
Syntax:
1. P1112
If either INS11 or INS12 is present, then the other is required.
DIAGRAM
INS01
INS
1073
INS02
✽ Yes/No Cond ✽
Resp Code
M
ID
INS07
1/1
M
1219
1069
Individual
Relat Code
ID
INS08
INS03
875
INS04
1203
INS05
2/2
O
584
INS09
ID
3/3
O
1220
ID
INS10
2/3
O
1073
ID
INS13
O
O
1165
Confident
Code
✽
64
1/2
ID
1/1
ID
INS14
2/2
19
City
Name
✽
O
O
AN 2/30
Original Page 118 Dated May 2000
ID
INS15
✽
1/1
156
State or
Prov Code
O
O
ID
2/2
ID
1/1
INS16
INS06
O
ID
2/3
1/1
ID
INS17
O
ID
1/1
1251
Date Time
Period
✽
X
AN 1/35
1470
Number
✽
INS12
2/3
1218
Medicare
Plan Code
O
1250
Date Time
format Qual
X
26
Country
Code
✽
ID
INS11
Student
✽ COBRA Qual ✽ Employment ✽
✽ Yes/No Cond ✽
Event Code
Status Code
Status Code
Resp Code
O
1216
Maintain
Benefit
✽ Maintenance ✽
✽
✽
Type Code
Reason Code
Status Code
N0
~
1/9
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
Loop ID Changed
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
INS01
DATA
ELEMENT
1073
NAME
ATTRIBUTES
Yes/No Condition or Response Code
M
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Insured
Indicator
INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.
SEMANTIC:
CODE
N
REQUIRED
INS02
1069
DEFINITION
No
Individual Relationship Code
M
ID
2/2
Code indicating the relationship between two individuals or entities
ALIAS: Relationship
CODE
OCTOBER 2002
to Insured Code
DEFINITION
01
Spouse
04
Grandfather or Grandmother
05
Grandson or Granddaughter
07
Nephew or Niece
09
Adopted Child
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Employee
21
Unknown
22
Handicapped Dependent
23
Sponsored Dependent
24
Dependent of a Minor Dependent
29
Significant Other
32
Mother
33
Father
34
Other Adult
36
Emancipated Minor
39
Organ Donor
40
Cadaver Donor
41
Injured Plaintiff
Original Page 119 Dated May 2000
65
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
Loop ID Changed
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
43
Child Where Insured Has No Financial Responsibility
53
Life Partner
G8
Other Relationship
NOT USED
INS03
875
Maintenance Type Code
O
ID
3/3
NOT USED
INS04
1203
Maintenance Reason Code
O
ID
2/3
NOT USED
INS05
1216
Benefit Status Code
O
ID
1/1
NOT USED
INS06
1218
Medicare Plan Code
O
ID
1/1
NOT USED
INS07
1219
Consolidated Omnibus Budget Reconciliation
Act (COBRA) Qualifying
O
ID
1/2
NOT USED
INS08
584
Employment Status Code
O
ID
2/2
NOT USED
INS09
1220
Student Status Code
O
ID
1/1
NOT USED
INS10
1073
Yes/No Condition or Response Code
O
ID
1/1
NOT USED
INS11
1250
Date Time Period Format Qualifier
X
ID
2/3
NOT USED
INS12
1251
Date Time Period
X
AN
1/35
NOT USED
INS13
1165
Confidentiality Code
O
ID
1/1
NOT USED
INS14
19
City Name
O
AN
2/30
NOT USED
INS15
156
State or Province Code
O
ID
2/2
NOT USED
INS16
26
Country Code
O
ID
2/3
SITUATIONAL
INS17
1470
Number
O
N0
1/9
A generic number
INDUSTRY: Birth
Sequence Number
INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).
SEMANTIC:
1294
66
This data element is not used unless the dependent is a child from
a multiple birth.
Original Page 120 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • TRN
SERVICE TRACE NUMBER
004010X094A1
SERVICE TRACE
NUMBER
• 278
• 2000F • TRN
IMPLEMENTATION
SERVICE TRACE NUMBER
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 2
Notes:
0
146
1. Use this segment to assign a unique trace number to this service
request. It is recommended that requesters assign a unique trace
number to each service request. The requester can send one TRN
segment in each service level (Loop 2000F) on the request to aid in
the reconciliation of the 278 response.
1
132
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.
2
132
3. Each trace number provided in the TRN segment at this level on the
request must be returned by the UMO in the TRN segment at the
corresponding level of the response.
New Note 4. Added
011
100
6
4. If the request contains more than one occurrence of Loop 2000F and
the requester needs to uniquely identify each service level request
this TRN segment is required in each Service loop.
Example: TRN✽1✽111099✽9012345678✽RADIOLOGY~
0
132
STANDARD
TRN Trace
Level: Detail
Position: 020
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To uniquely identify a transaction to an application
DIAGRAM
TRN01
TRN ✽
M
OCTOBER 2002
481
Trace Type
Code
ID
1/2
TRN02
✽
127
Reference
Ident
M
AN 1/30
TRN03
509
✽ Originating ✽
Company ID
O
AN 10/10
TRN04
127
Reference
Ident
O
~
AN 1/30
Original Page 139 Dated May 2000
67
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
PROCEDURES• 278 • 2000F • HI
IMPLEMENTATION
PROCEDURES
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:
4
134
1. Use this segment to request specific services and procedures.
2. Use the most current version of the code list identified in HIxx-1 Code
List Qualifier Code (Data Element 1270).
5
134
Example: HI✽BO✽49000:D8:19950121::1~
009
100
3
STANDARD
HI Health Care Information Codes
Level: Detail
Position: 080
Loop: HL
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the delivery of health care
DIAGRAM
HI01
HI
C022
HI02
C022
HI03
C022
HI04
C022
HI05
C022
HI06
C022
✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care ✽ Health Care
Code Info.
Code Info.
M
HI07
✽
Code Info.
O
C022
Health Care
Code Info.
HI08
✽
O
Code Info.
O
C022
Health Care
Code Info.
HI09
✽
O
Code Info.
O
C022
Health Care
Code Info.
O
HI10
✽
Code Info.
O
C022
Health Care
Code Info.
HI11
✽
O
O
C022
Health Care
Code Info.
HI12
✽
O
C022
Health Care
Code Info.
~
O
ELEMENT SUMMARY
REF.
DES.
USAGE
REQUIRED
HI01
DATA
ELEMENT
C022
NAME
ATTRIBUTES
HEALTH CARE CODE INFORMATION
M
To send health care codes and their associated dates, amounts and quantities
ALIAS: Procedure
1129
REQUIRED
HI01 - 1
1270
Code 1
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
1000117
68
Original Page 159 Dated May 2000
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI01 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI01 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI01 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
OCTOBER 2002
Date
HI01 - 5
Usage Changed
Industry Name Added
New Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page 160 Dated May 2000
69
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI01 - 6
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI01-2 for the
same time period.
1347
SITUATIONAL
HI01 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI01-1 has a version
identifier. Otherwise Not Used.
1348
SITUATIONAL
HI02
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1130
ALIAS: Procedure
1405
Use this for the second procedure.
REQUIRED
HI02 - 1
1270
Code 2
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
70
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Numbers 160 and 161 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI02 - 2
004010X094A1 • 278 • 2000F • HI
PROCEDURES
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI02 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI02 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
Date
HI02 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI02 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI02-2 for the
same time period.
1425
SITUATIONAL
Quantity
HI02 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI02-1 has a version
identifier. Otherwise Not Used.
1426
SITUATIONAL
Release, or Industry Identifier
HI03
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1131
ALIAS: Procedure
1406
Use this for the third procedure.
REQUIRED
HI03 - 1
1270
Code 3
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000117
OCTOBER 2002
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Numbers 161 and 162 Dated May 2000
71
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI03 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI03 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI03 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
72
Date
HI03 - 5
Usage Changed
Industry Name Added
Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page Numbers 162 and 163 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI03 - 6
004010X094A1 • 278 • 2000F • HI
PROCEDURES
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI03-2 for the
same time period.
1427
SITUATIONAL
Quantity
HI03 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI03-1 has a version
identifier. Otherwise Not Used.
1428
SITUATIONAL
Release, or Industry Identifier
HI04
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1132
ALIAS: Procedure
1407
Use this for the fourth procedure.
REQUIRED
HI04 - 1
1270
Code 4
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
OCTOBER 2002
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Number 163 Dated May 2000
73
004010X094A1 • 278 • 2000F • HI
PROCEDURES
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI04 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI04 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI04 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
Date
HI04 - 5
782
HI04 - 6
Monetary Amount
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI04-2 for the
same time period.
1429
SITUATIONAL
Quantity
HI04 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI04-1 has a version
identifier. Otherwise Not Used.
1430
SITUATIONAL
Release, or Industry Identifier
HI05
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1133
ALIAS: Procedure
1408
Use this for the fifth procedure.
REQUIRED
HI05 - 1
1270
Code 5
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000117
74
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Numbers 163 and 164 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI05 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI05 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI05 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
OCTOBER 2002
Date
HI05 - 5
Usage Changed
Industry Name Added
Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page Number 165 Dated May 2000
75
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI05 - 6
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI05-2 for the
same time period.
1431
SITUATIONAL
Quantity
HI05 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI05-1 has a version
identifier. Otherwise Not Used.
1432
SITUATIONAL
Release, or Industry Identifier
HI06
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1134
ALIAS: Procedure
1409
Use this for the sixth procedure.
REQUIRED
HI06 - 1
1270
Code 6
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
76 Original Page Numbers 165 and 166 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI06 - 2
004010X094A1 • 278 • 2000F • HI
PROCEDURES
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI06 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI06 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
Date
HI06 - 5
782
HI06 - 6
Monetary Amount
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI06-2 for the
same time period.
1433
SITUATIONAL
Quantity
HI06 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI06-1 has a version
identifier. Otherwise Not Used.
1434
SITUATIONAL
Release, or Industry Identifier
HI07
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1135
ALIAS: Procedure
1410
Use this for the seventh procedure.
REQUIRED
HI07 - 1
1270
Code 7
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000117
OCTOBER 2002
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Number 166 to 167Dated May 2000
77
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI07 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI07 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI07 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
78
Date
HI07 - 5
Usage Changed
Industry Name Added
Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page Number 167 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI07 - 6
004010X094A1 • 278 • 2000F • HI
PROCEDURES
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI07-2 for the
same time period.
1435
SITUATIONAL
Quantity
HI07 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI07-1 has a version
identifier. Otherwise Not Used.
1436
SITUATIONAL
Release, or Industry Identifier
HI08
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1136
ALIAS: Procedure
1411
Use this for the eighth procedure.
REQUIRED
HI08 - 1
1270
Code 8
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
OCTOBER 2002
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Number 167 to 168 Dated May 2000
79
004010X094A1 • 278 • 2000F • HI
PROCEDURES
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI08 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI08 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI08 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
Date
HI08 - 5
782
HI08 - 6
Monetary Amount
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI08-2 for the
same time period.
1437
SITUATIONAL
Quantity
HI08 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI08-1 has a version
identifier. Otherwise Not Used.
1438
SITUATIONAL
Release, or Industry Identifier
HI09
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1137
ALIAS: Procedure
1412
Use this for the ninth procedure.
REQUIRED
HI09 - 1
1270
Code 9
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000117
80
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Numbers 168 and 169 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI09 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI09 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI09 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
OCTOBER 2002
Date
HI09 - 5
Usage Changed
Industry Name Added
Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page Number 169 to 170 Dated May 2000
81
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI09 - 6
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI09-2 for the
same time period.
1439
SITUATIONAL
Quantity
HI09 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI09-1 has a version
identifier. Otherwise Not Used.
1440
SITUATIONAL
Release, or Industry Identifier
HI10
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1138
ALIAS: Procedure
1413
Use this for the tenth procedure.
REQUIRED
HI10 - 1
1270
Code 10
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
82
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Numbers 170 and 171 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI10 - 2
004010X094A1 • 278 • 2000F • HI
PROCEDURES
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI10 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI10 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
HI10 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI10 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI10-2 for the
same time period.
1441
SITUATIONAL
HI10 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI10-1 has a version
identifier. Otherwise Not Used.
1442
SITUATIONAL
HI11
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1139
ALIAS: Procedure
1414
Use this for the eleventh procedure.
REQUIRED
HI11 - 1
1270
Code 11
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000117
OCTOBER 2002
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Number 171 Dated May 2000
83
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
1000115
New Note Added
REQUIRED
American Dental Association Codes
HI11 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI11 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI11 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
84
Date
HI11 - 5
Usage Changed
Industry Name Added
Note Added
782
Monetary Amount
O
R
1/18
Monetary amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
Original Page Number 172 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI11 - 6
004010X094A1 • 278 • 2000F • HI
PROCEDURES
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI11-2 for the
same time period.
1443
SITUATIONAL
Quantity
HI11 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI11-1 has a version
identifier. Otherwise Not Used.
1444
SITUATIONAL
Release, or Industry Identifier
HI12
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1140
ALIAS: Procedure
1415
Use this for the twelfth procedure.
REQUIRED
HI12 - 1
1270
Code 12
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000117
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1402
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1000115
New Note Added
OCTOBER 2002
American Dental Association Codes
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product/Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Number 172 to 173 Dated May 2000
85
004010X094A1 • 278 • 2000F • HI
PROCEDURES
REQUIRED
HI12 - 2
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI12 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1216
CODE
SITUATIONAL
HI12 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1346
SITUATIONAL
1000118
SITUATIONAL
Date
HI12 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI12 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the procedure charge amount is needed by the UMO
to approve a monetary limitation for the health care
services requested.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI12-2 for the
same time period.
1445
SITUATIONAL
Quantity
HI12 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
1446
86
Release, or Industry Identifier
Required if the code list referenced in HI12-1 has a version
identifier. Otherwise Not Used.
Original Page Numbers 173 and 174 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
004010X094A1
PATIENT CONDITION
2000F • CRC
• 278 •INFORMATION
IMPLEMENTATION
PATIENT CONDITION INFORMATION
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 6
Notes:
9
134
1. Use this segment to provide additional patient condition information
needed to justify the medical necessity of the services requested.
Example: CRC✽75✽Y✽12~
3
104
STANDARD
CRC Conditions Indicator
Level: Detail
Position: 100
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To supply information on conditions
DIAGRAM
CRC01
CRC ✽
M
ID
CRC07
✽
1136
Code
Category
2/2
ID
1073
M
ID
1/1
CRC03
1321
Certificate
Cond Code
M
ID
2/2
CRC04
✽
1321
Certificate
Cond Code
O
ID
CRC05
✽
2/2
1321
Certificate
Cond Code
O
ID
CRC06
✽
2/2
1321
Certificate
Cond Code
O
ID
2/2
1321
Certificate
Cond Code
O
CRC02
✽ Yes/No Cond ✽
Resp Code
~
2/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
CRC01
DATA
ELEMENT
1136
NAME
ATTRIBUTES
Code Category
M
ID
2/2
Specifies the situation or category to which the code applies
ALIAS: Condition
SEMANTIC:
CODE
OCTOBER 2002
Code Category
CRC01 qualifies CRC03 through CRC07.
DEFINITION
07
Ambulance Certification
08
Chiropractic Certification
11
Oxygen Therapy Certification
75
Functional Limitations
Original Page Number 180 Dated May 2000
87
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
REQUIRED
CRC02
1073
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
76
Activities Permitted
77
Mental Status
Yes/No Condition or Response Code
M
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Certification
Condition Indicator
CRC02 is a Certification Condition Code applies indicator. A “Y” value
indicates the condition codes in CRC03 through CRC07 apply; an “N” value
indicates the condition codes in CRC03 through CRC07 do not apply.
SEMANTIC:
CODE
REQUIRED
CRC03
1321
DEFINITION
N
No
Y
Yes
Condition Indicator
M
ID
2/2
Code indicating a condition
INDUSTRY: Condition
CODE
88
Code
DEFINITION
01
Patient was admitted to a hospital
02
Patient was bed confined before the ambulance
service
03
Patient was bed confined after the ambulance
service
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
10
Patient is ambulatory
11
Ambulation is Impaired and Walking Aid is Used for
Therapy or Mobility
12
Patient is confined to a bed or chair
13
Patient is Confined to a Room or an Area Without
Bathroom Facilities
14
Ambulation is Impaired and Walking Aid is Used for
Mobility
15
Patient Condition Requires Positioning of the Body
or Attachments Which Would Not be Feasible With
the Use of an Ordinary Bed
Original Page Number 181 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Codes Added
OCTOBER 2002
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
16
Patient needs a trapeze bar to sit up due to
respiratory condition or change body positions for
other medical reasons
17
Patient’s Ability to Breathe is Severely Impaired
18
Patient condition requires frequent and/or
immediate changes in body positions
19
Patient can operate controls
20
Siderails Are to be Attached to a Hospital Bed
Owned by the Beneficiary
21
Patient owns equipment
22
Mattress or Siderails are Being Used with
Prescribed Medically Necessary Hospital Bed
Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to
Assist in Transfer from Bed to Wheelchair
24
Patient has an orthopedic impairment requiring
traction equipment which prevents ambulation
during period of use
25
Item has been prescribed as part of a planned
regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of
equipment
30
Without the equipment, the patient would require
surgery
31
Patient has had a total knee replacement
35
This Feeding is the Only Form of Nutritional Intake
for This Patient
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the
Equipment Without Technical or Professional
Supervision
41
Patient or Caregiver is Unable to Propel or Lift a
Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body
Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy
Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
Original Page Number 182 Dated May 2000
89
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
New Codes Added
SITUATIONAL
CRC04
1321
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into
Wheelchair, Commode or Other
60
Transportation Was To the Nearest Facility
9D
Lack of Appropriate Facility within Reasonable
Distance to Treat Patient in the Event of
Complications
9H
Patient Requires Intensive IV Therapy
9J
Patient Requires Protective Isolation
9K
Patient Requires Frequent Monitoring
IH
Independent at Home
LB
Legally Blind
SL
Speech Limitations
Condition Indicator
O
ID
2/2
Code indicating a condition
INDUSTRY: Condition
Code
1210
Use this data element to specify additional codes indicating a
patient’s condition.
1219
Use if multiple conditions apply to the certification.
CODE
90
DEFINITION
01
Patient was admitted to a hospital
02
Patient was bed confined before the ambulance
service
03
Patient was bed confined after the ambulance
service
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
10
Patient is ambulatory
11
Ambulation is Impaired and Walking Aid is Used for
Therapy or Mobility
12
Patient is confined to a bed or chair
Original Page Numbers 182 and 183 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Codes Added
OCTOBER 2002
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
13
Patient is Confined to a Room or an Area Without
Bathroom Facilities
14
Ambulation is Impaired and Walking Aid is Used for
Mobility
15
Patient Condition Requires Positioning of the Body
or Attachments Which Would Not be Feasible With
the Use of an Ordinary Bed
16
Patient needs a trapeze bar to sit up due to
respiratory condition or change body positions for
other medical reasons
17
Patient’s Ability to Breathe is Severely Impaired
18
Patient condition requires frequent and/or
immediate changes in body positions
19
Patient can operate controls
20
Siderails Are to be Attached to a Hospital Bed
Owned by the Beneficiary
21
Patient owns equipment
22
Mattress or Siderails are Being Used with
Prescribed Medically Necessary Hospital Bed
Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to
Assist in Transfer from Bed to Wheelchair
24
Patient has an orthopedic impairment requiring
traction equipment which prevents ambulation
during period of use
25
Item has been prescribed as part of a planned
regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of
equipment
30
Without the equipment, the patient would require
surgery
31
Patient has had a total knee replacement
35
This Feeding is the Only Form of Nutritional Intake
for This Patient
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the
Equipment Without Technical or Professional
Supervision
Original Page Number 183 Dated May 2000
91
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
New Codes Added
SITUATIONAL
CRC05
1321
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
41
Patient or Caregiver is Unable to Propel or Lift a
Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body
Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy
Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into
Wheelchair, Commode or Other
60
Transportation Was To the Nearest Facility
9D
Lack of Appropriate Facility within Reasonable
Distance to Treat Patient in the Event of
Complications
9H
Patient Requires Intensive IV Therapy
9J
Patient Requires Protective Isolation
9K
Patient Requires Frequent Monitoring
IH
Independent at Home
LB
Legally Blind
SL
Speech Limitations
Condition Indicator
O
ID
2/2
Code indicating a condition
INDUSTRY: Condition
Code
1210
Use this data element to specify additional codes indicating a
patient’s condition.
1219
Use if multiple conditions apply to the certification.
CODE
92
DEFINITION
01
Patient was admitted to a hospital
02
Patient was bed confined before the ambulance
service
03
Patient was bed confined after the ambulance
service
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
Original Page Numbers 183 and 184 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Codes Added
OCTOBER 2002
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
09
Ambulance service was medically necessary
10
Patient is ambulatory
11
Ambulation is Impaired and Walking Aid is Used for
Therapy or Mobility
12
Patient is confined to a bed or chair
13
Patient is Confined to a Room or an Area Without
Bathroom Facilities
14
Ambulation is Impaired and Walking Aid is Used for
Mobility
15
Patient Condition Requires Positioning of the Body
or Attachments Which Would Not be Feasible With
the Use of an Ordinary Bed
16
Patient needs a trapeze bar to sit up due to
respiratory condition or change body positions for
other medical reasons
17
Patient’s Ability to Breathe is Severely Impaired
18
Patient condition requires frequent and/or
immediate changes in body positions
19
Patient can operate controls
20
Siderails Are to be Attached to a Hospital Bed
Owned by the Beneficiary
21
Patient owns equipment
22
Mattress or Siderails are Being Used with
Prescribed Medically Necessary Hospital Bed
Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to
Assist in Transfer from Bed to Wheelchair
24
Patient has an orthopedic impairment requiring
traction equipment which prevents ambulation
during period of use
25
Item has been prescribed as part of a planned
regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of
equipment
30
Without the equipment, the patient would require
surgery
31
Patient has had a total knee replacement
35
This Feeding is the Only Form of Nutritional Intake
for This Patient
Original Page Numbers 184 and 185 Dated May 2000
93
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
New Codes Added
SITUATIONAL
CRC06
1321
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the
Equipment Without Technical or Professional
Supervision
41
Patient or Caregiver is Unable to Propel or Lift a
Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body
Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy
Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into
Wheelchair, Commode or Other
60
Transportation Was To the Nearest Facility
9D
Lack of Appropriate Facility within Reasonable
Distance to Treat Patient in the Event of
Complications
9H
Patient Requires Intensive IV Therapy
9J
Patient Requires Protective Isolation
9K
Patient Requires Frequent Monitoring
IH
Independent at Home
LB
Legally Blind
SL
Speech Limitations
Condition Indicator
O
ID
2/2
Code indicating a condition
INDUSTRY: Condition
Code
1210
Use this data element to specify additional codes indicating a
patient’s condition.
1219
Use if multiple conditions apply to the certification.
CODE
94
DEFINITION
01
Patient was admitted to a hospital
02
Patient was bed confined before the ambulance
service
03
Patient was bed confined after the ambulance
service
04
Patient was moved by stretcher
Original Page Numbers 184 and 185 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
10
Patient is ambulatory
11
Ambulation is Impaired and Walking Aid is Used for
Therapy or Mobility
12
Patient is confined to a bed or chair
13
Patient is Confined to a Room or an Area Without
Bathroom Facilities
14
Ambulation is Impaired and Walking Aid is Used for
Mobility
15
Patient Condition Requires Positioning of the Body
or Attachments Which Would Not be Feasible With
the Use of an Ordinary Bed
16
Patient needs a trapeze bar to sit up due to
respiratory condition or change body positions for
other medical reasons
17
Patient’s Ability to Breathe is Severely Impaired
18
Patient condition requires frequent and/or
immediate changes in body positions
19
Patient can operate controls
20
Siderails Are to be Attached to a Hospital Bed
Owned by the Beneficiary
21
Patient owns equipment
22
Mattress or Siderails are Being Used with
Prescribed Medically Necessary Hospital Bed
Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to
Assist in Transfer from Bed to Wheelchair
24
Patient has an orthopedic impairment requiring
traction equipment which prevents ambulation
during period of use
25
Item has been prescribed as part of a planned
regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of
equipment
Original Page Numbers 185 and 186 Dated May 2000
95
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
New Codes Added
SITUATIONAL
CRC07
1321
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
30
Without the equipment, the patient would require
surgery
31
Patient has had a total knee replacement
35
This Feeding is the Only Form of Nutritional Intake
for This Patient
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the
Equipment Without Technical or Professional
Supervision
41
Patient or Caregiver is Unable to Propel or Lift a
Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body
Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy
Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into
Wheelchair, Commode or Other
60
Transportation Was To the Nearest Facility
9D
Lack of Appropriate Facility within Reasonable
Distance to Treat Patient in the Event of
Complications
9H
Patient Requires Intensive IV Therapy
9J
Patient Requires Protective Isolation
9K
Patient Requires Frequent Monitoring
IH
Independent at Home
LB
Legally Blind
SL
Speech Limitations
Condition Indicator
O
ID
2/2
Code indicating a condition
INDUSTRY: Condition
Code
1210
Use this data element to specify additional codes indicating a
patient’s condition.
1219
Use if multiple conditions apply to the certification.
CODE
01
DEFINITION
Patient was admitted to a hospital
96 Original Page Numbers 186 and 187 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OCTOBER 2002
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
02
Patient was bed confined before the ambulance
service
03
Patient was bed confined after the ambulance
service
04
Patient was moved by stretcher
05
Patient was unconscious or in shock
06
Patient was transported in an emergency situation
07
Patient had to be physically restrained
08
Patient had visible hemorrhaging
09
Ambulance service was medically necessary
10
Patient is ambulatory
11
Ambulation is Impaired and Walking Aid is Used for
Therapy or Mobility
12
Patient is confined to a bed or chair
13
Patient is Confined to a Room or an Area Without
Bathroom Facilities
14
Ambulation is Impaired and Walking Aid is Used for
Mobility
15
Patient Condition Requires Positioning of the Body
or Attachments Which Would Not be Feasible With
the Use of an Ordinary Bed
16
Patient needs a trapeze bar to sit up due to
respiratory condition or change body positions for
other medical reasons
17
Patient’s Ability to Breathe is Severely Impaired
18
Patient condition requires frequent and/or
immediate changes in body positions
19
Patient can operate controls
20
Siderails Are to be Attached to a Hospital Bed
Owned by the Beneficiary
21
Patient owns equipment
22
Mattress or Siderails are Being Used with
Prescribed Medically Necessary Hospital Bed
Owned by the Beneficiary
23
Patient Needs Lift to Get In or Out of Bed or to
Assist in Transfer from Bed to Wheelchair
24
Patient has an orthopedic impairment requiring
traction equipment which prevents ambulation
during period of use
Original Page Number 187 Dated May 2000
97
004010X094A1 • 278 • 2000F • CRC
PATIENT CONDITION INFORMATION
New Codes Added
98
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
25
Item has been prescribed as part of a planned
regimen of treatment in patient home
26
Patient is highly susceptible to decubitus ulcers
27
Patient or a care-giver has been instructed in use of
equipment
30
Without the equipment, the patient would require
surgery
31
Patient has had a total knee replacement
35
This Feeding is the Only Form of Nutritional Intake
for This Patient
37
Oxygen delivery equipment is stationary
39
Patient Has Mobilizing Respiratory Tract Secretions
40
Patient or Caregiver is Capable of Using the
Equipment Without Technical or Professional
Supervision
41
Patient or Caregiver is Unable to Propel or Lift a
Standard Weight Wheelchair
42
Patient Requires Leg Elevation for Edema or Body
Alignment
43
Patient Weight or Usage Needs Necessitate a Heavy
Duty Wheelchair
44
Patient Requires Reclining Function of a Wheelchair
45
Patient is Unable to Operate a Wheelchair Manually
46
Patient or Caregiver Requires Side Transfer into
Wheelchair, Commode or Other
60
Transportation Was To the Nearest Facility
9D
Lack of Appropriate Facility within Reasonable
Distance to Treat Patient in the Event of
Complications
9H
Patient Requires Intensive IV Therapy
9J
Patient Requires Protective Isolation
9K
Patient Requires Frequent Monitoring
IH
Independent at Home
LB
Legally Blind
SL
Speech Limitations
Original Page Number 187 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
PAPERWORK
PWK
New Segment Added
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
004010X094A1
ADDITIONAL SERVICE
INFORMATION
• 278 • 2000F
• PWK
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
012
100
0
1. This PWK segment is required if the requester has additional
documentation (electronic, paper, or other medium) associated with
this health care services review that applies to the service(s)
requested in this Service loop. This PWK segment should not be used
if
a. the 278 request (ST-SE) supports this information in its segments
and data elements, or
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to the health care services review and
not to a specific service.
010
100
1
2. This PWK segment is required to identify attachments that are sent
electronically (PWK02 = EL) but are transmitted in another X12
functional group rather than by paper or other medium. PWK06 is
used to identify the attached electronic documentation. The number in
PWK06 would be referenced in the electronic attachment.
010
100
2
3. The requester can also use this PWK segment to identify paperwork
that is held at the provider’s office and is available upon request by
the UMO (or appropriate entity). Use code AA in PWK02 to convey this
specific use of the PWK segment. See code note under PWK02, code
AA.
Refer to Section 2.2.5 for more information on using this PWK
segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
009
100
8
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
OCTOBER 2002
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
New Page inserted after page 210 dated May 2000
99
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
DIAGRAM
PWK01
PWK
755
PWK02
756
PWK03
757
PWK04
Report
Report
✽ Report Type ✽
✽
✽
Copies Need
Code
Transm Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
ID
O
ID
PWK05
✽
2/3
66
ID Code
Qualifier
X
ID
PWK06
✽
1/2
67
ID
Code
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
Report Type Code
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000103
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000104
59
Benefit Letter
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
100 New Page inserted after page 210 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000105
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000106
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000107
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000108
OCTOBER 2002
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
New Page inserted after page 210 dated May 2000
101
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
REQUIRED
PWK02
756
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
AA
Transmission Code
DEFINITION
Available on Request at Provider Site
This means that the paperwork is not being sent
with the request at this time. Instead, it is available
to the UMO (or appropriate entity) on request.
1000109
BM
By Mail
EL
Electronically Only
Use to indicate that the attachment is being
transmitted in a separate X12 functional group.
1000110
EM
E-Mail
102 New Page inserted after page 210 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
FX
By Fax
VO
Voice
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
Use this for voicemail or phone communication.
1000111
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “AA”
or “VO”. The requester can use it when PWK02 equals “AA” if the
requester wants to send a document control number for an
attachment remaining at the Provider’s office.
1000112
CODE
DEFINITION
AC
SITUATIONAL
PWK06
67
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
Required if PWK02 equals BM, EL, EM or FX.
1000113
SITUATIONAL
Control Number
P0506
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
Description
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000114
NOT USED
PWK08
C002
ACTIONS INDICATED
O
NOT USED
PWK09
1525
Request Category Code
O
OCTOBER 2002
ID
New Page inserted after page 210 dated May 2000
1/2
103
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278
004010X094A1 • 278
IMPLEMENTATION
278
Health Care Services Review — Response to Request for
Review
It is recommended that separate transaction sets be used for different patients.
Table 1 - Header
PAGE #
256
257
POS. # SEG. ID
010
020
ST
BHT
NAME
USAGE
R
R
Transaction Set Header
Beginning of Hierarchical Transaction
REPEAT
LOOP REPEAT
1
1
Table 2 - Utilization Management Organization (UMO) Detail
PAGE #
259
261
POS. # SEG. ID
010
030
HL
AAA
263
266
170
220
NM1
PER
269
230
AAA
NAME
USAGE
LOOP ID - 2000A UTILIZATION MANAGEMENT
ORGANIZATION (UMO) LEVEL
Utilization Management Organization (UMO) Level
Request Validation
REPEAT
LOOP REPEAT
1
R
S
LOOP ID - 2010A UTILIZATION MANAGEMENT
ORGANIZATION (UMO) NAME
Utilization Management Organization (UMO) Name
Utilization Management Organization (UMO) Contact
Information
Utilization Management Organization (UMO) Request
Validation
1
9
1
R
S
1
1
S
9
Table 2 - Requester Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
272
010
HL
LOOP ID - 2000B REQUESTER LEVEL
Requester Level
R
1
274
277
279
281
170
180
230
240
NM1
REF
AAA
PRV
LOOP ID - 2010B REQUESTER NAME
Requester Name
Requester Supplemental Identification
Requester Request Validation
Requester Provider Information
R
S
S
S
1
8
9
1
LOOP REPEAT
1
1
Table 2 - Subscriber Detail
PAGE #
283
286
288
POS. # SEG. ID
010
020
030
HL
TRN
AAA
NAME
LOOP ID - 2000C SUBSCRIBER LEVEL
Subscriber Level
New Segment
Patient Event Tracking Number
Subscriber Request Validation
104 Original Page Number 213 Dated May 2000
USAGE
REPEAT
LOOP REPEAT
1
Added
R
S
S
1
3
9
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
290
291
292
293
294
305
310
313
315
317
319
323
324
326
070
070
070
070
080
155
170
180
230
250
170
200
210
220
004010X094A1 • 278
DTP
DTP
DTP
DTP
HI
PWK
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Subscriber Diagnosis
Additional Patient Information
New Segment
NM1
REF
AAA
DMG
LOOP ID - 2010CA SUBSCRIBER NAME
Segment
Subscriber Name
Subscriber Supplemental Identification
Subscriber Request Validation
Subscriber Demographic Information
NM1
N3
N4
PER
LOOP ID - 2010CB ADDITIONAL PATIENT
New Loop Added
INFORMATION CONTACT NAME
Additional Patient Information Contact Name
S
Additional Patient Information Contact Address
S
Additional Patient Information Contact City/State/Zip Code
S
Additional Patient Information Contact Information
S
S
S
S
S
S
S
1
1
1
1
1
10
ID Changed R
1
9
9
1
Added
1
S
S
S
1
1
1
1
1
Table 2 - Dependent Detail
PAGE #
POS. # SEG. ID
NAME
USAGE
REPEAT
330
332
335
337
338
339
340
341
352
010
020
030
070
070
070
070
080
155
HL
TRN
AAA
DTP
DTP
DTP
DTP
HI
PWK
LOOP ID - 2000D DEPENDENT LEVEL
Dependent Level
New Segment Added
Patient Event Tracking Number
Dependent Request Validation
Accident Date
Last Menstrual Period Date
Estimated Date of Birth
Onset of Current Symptoms or Illness Date
Dependent Diagnosis
Additional Patient Information
New Segment Added
S
S
S
S
S
S
S
S
S
1
3
9
1
1
1
1
1
10
357
360
362
364
366
170
180
230
250
260
NM1
REF
AAA
DMG
INS
LOOP ID - 2010DA DEPENDENT NAME
Loop ID Changed
Dependent Name
Dependent Supplemental Identification
Dependent Request Validation
Dependent Demographic Information
Dependent Relationship
R
S
S
S
S
1
3
9
1
1
NM1
N3
N4
PER
LOOP ID - 2010DB ADDITIONAL PATIENT
INFORMATION CONTACT NAME
New Loop Added
Additional Patient Information Contact Name
S
Additional Patient Information Contact Address
S
Additional Patient Information Contact City/State/Zip Code
S
Additional Patient Information Contact Information
S
369
373
374
376
170
200
210
220
OCTOBER 2002
LOOP REPEAT
1
1
1
1
1
1
1
Original Page Number 214 Dated May 2000
105
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278
Table 2 - Service Provider Detail
PAGE #
POS. # SEG. ID
NAME
380
382
010
160
HL
MSG
LOOP ID - 2000E SERVICE PROVIDER LEVEL
Service Provider Level
Message Text
383
386
388
389
391
394
396
170
180
200
210
220
230
240
NM1
REF
N3
N4
PER
AAA
PRV
LOOP ID - 2010E SERVICE PROVIDER NAME
Service Provider Name
Service Provider Supplemental Identification
Service Provider Address
Service Provider City/State/ZIP Code
Service Provider Contact Information
Service Provider Request Validation
Service Provider Information
USAGE
REPEAT
LOOP REPEAT
>1
R
S
1
1
R
S
S
S
S
S
S
1
7
1
1
1
9
1
3
Table 2 - Service Detail
PAGE #
398
400
403
405
411
414
415
417
419
421
423
424
425
426
446
451
453
455
460
464
467
472
473
477
478
480
484
106
POS. # SEG. ID
010
020
030
040
050
060
070
070
070
070
070
070
070
080
090
110
120
130
140
150
155
160
170
200
210
220
280
NAME
USAGE
HL
TRN
AAA
UM
HCR
REF
DTP
DTP
DTP
DTP
DTP
DTP
DTP
HI
HSD
CL1
CR1
CR2
CR5
CR6
PWK
MSG
LOOP ID - 2000F SERVICE LEVEL
Service Level
Service Trace Number
Service Request Validation
Health Care Services Review Information
Health Care Services Review
Previous Certification Identification
Service Date
Admission Date
Discharge Date
Surgery Date
Certification Issue Date
Certification Expiration Date
Certification Effective Date
Procedures
Health Care Services Delivery
Institutional Claim Code
Ambulance Transport Information
Spinal Manipulation Service Information
Home Oxygen Therapy Information
Home Health Care Information
Additional Service Information
New Segment
Message Text
NM1
N3
N4
PER
SE
LOOP ID - 2010F ADDITIONAL SERVICE
New Loop
INFORMATION CONTACT NAME
S
Additional Service Information Contact Name
S
Additional Service Information Contact Address
S
Additional Service Information Contact City/State/Zip Code
S
Additional Service Information Contact Information
R
Transaction Set Trailer
Original Page Number 215 Dated May 2000
REPEAT
LOOP REPEAT
>1
Added
R
S
S
R
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
1
3
9
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
10
1
1
Added
1
1
1
1
1
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • BHT
BEGINNING OF HIERARCHICAL TRANSACTION
004010X094A1
BEGINNING
OF•HIERARCHICAL
278 • BHT
TRANSACTION
REQUIRED
BHT03
127
Reference Identification
O
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Submitter
Transaction Identifier
BHT03 is the number assigned by the originator to identify the
transaction within the originator’s business application system.
SEMANTIC:
Return the transaction identifier entered in BHT03 on the 278
request.
1228
REQUIRED
BHT04
373
Date
O
DT
8/8
Date expressed as CCYYMMDD
INDUSTRY: Transaction
Set Creation Date
BHT04 is the date the transaction was created within the business
application system.
SEMANTIC:
REQUIRED
BHT05
337
Time
O
TM
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)
INDUSTRY: Transaction
Set Creation Time
BHT05 is the time the transaction was created within the business
application system.
SEMANTIC:
SITUATIONAL
BHT06
640
Transaction Type Code
O
ID
2/2
Code specifying the type of transaction
If BHT06 is not valued on the response, the value “18" (Response No Further Updates to Follow) is assumed.
1378
CODE
18
DEFINITION
Response - No Further Updates to Follow
Use this code to indicate that this is a final
response. If the final response reports a medical
decision it contains an HCR01 value of A1, A3, A6,
or NA in Loop 2000F. This indicates that no
additional EDI responses are necessary or
forthcoming from the UMO in relation to the original
request.
1226
Note: If you use HCR01 = CT to indicate a non-EDI
delivery of the medical decision, use it in
combination with BHT06 = 18.
Note moved
from Code 19
to Code 18
19
1227
Use this code to indicate that the final medical
decision is pending further review. A pended
response contains an HCR01 value of A4 or CT.
This, in combination with BHT06 = 19, indicates that
the final EDI response will be delivered later.
Text Revised
New Code Added
Response - Further Updates to Follow
AT
Administrative Action
1227
BHT06 must be valued with “AT” if this 278
response contains a request for additional
information.
OCTOBER 2002
Original Page Number 220 Dated May 2000
107
004010X094A1 • 278 • 2000C • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
PATIENT
EVENT
TRACKING
• 278
• 2000CNUMBER
• TRN
IMPLEMENTATION
PATIENT EVENT TRACKING NUMBER
Loop: 2000C — SUBSCRIBER LEVEL
Usage: SITUATIONAL
Repeat: 3
Notes:
6
132
1. Any trace numbers provided at this level on the request must be
returned by the UMO at this level of the 278 response.
010
100
4
2. The UMO can assign a trace number to this patient event for tracking
purposes.
8
138
3. If the 278 request 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 should merely pass all TRN segments
received in the 278 response transaction.
4. 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.
9
138
Example: TRN✽2✽2001042801✽9012345678✽CARDIOLOGY~
010
100
3
STANDARD
TRN Trace
Level: Detail
Position: 020
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To uniquely identify a transaction to an application
108
New Page inserted after page 246 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000C • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
DIAGRAM
TRN01
TRN ✽
481
Trace Type
Code
M
ID
1/2
TRN02
✽
127
Reference
Ident
M
TRN03
509
TRN04
✽ Originating ✽
Company ID
AN 1/30
O
AN 10/10
127
Reference
Ident
O
~
AN 1/30
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
TRN01
DATA
ELEMENT
481
NAME
ATTRIBUTES
Trace Type Code
M
ID
1/2
Code identifying which transaction is being referenced
CODE
DEFINITION
1
Current Transaction Trace Numbers
The term “Current Transaction Trace Number”
refers to the trace number assigned by the creator
of the 278 response transaction (the UMO).
1328
2
Referenced Transaction Trace Numbers
The term “Referenced Transaction Trace Number”
refers to the trace number originally sent in the 278
request transaction.
1329
REQUIRED
TRN02
127
Reference Identification
M
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Patient
SEMANTIC:
REQUIRED
TRN03
509
Event Tracking Number
TRN02 provides unique identification for the transaction.
Originating Company Identifier
O
AN
10/10
A unique identifier designating the company initiating the funds transfer
instructions. The first character is one-digit ANSI identification code designation
(ICD) followed by the nine-digit identification number which may be an IRS
employer identification number (EIN), data universal numbering system (DUNS),
or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned
number is 9
INDUSTRY: Trace
SEMANTIC:
Assigning Entity Number
TRN03 identifies an organization.
1248
Use this element to identify the organization that assigned this
trace number. If TRN01 is “2", this is the value received in the
original 278 request transaction. If TRN01 is ”1", use this
information to identify the UMO organization that assigned this
trace number.
1249
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.
OCTOBER 2002
New Page inserted after page 246 dated May 2000
109
004010X094A1 • 278 • 2000C • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
SITUATIONAL
Reference Identification
TRN04
127
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
O
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Trace
SEMANTIC:
1250
110
Assigning Entity Additional Identifier
TRN04 identifies a further subdivision within the organization.
Use this information if necessary to further identify a specific
component, such as a specific division or group, of the company
identified in the previous data element (TRN03).
New Page inserted after page 246 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
004010X094A1DIAGNOSIS
SUBSCRIBER
• 278 • 2000C • HI
IMPLEMENTATION
SUBSCRIBER DIAGNOSIS
Loop: 2000C — SUBSCRIBER LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:
008
100
5
1. Required if valued on the request and used by the UMO to render a
decision. If the response has not been rendered and this segment is
used to request additional information associated with a specific
diagnosis, place the specific diagnosis code in the HI C022 composite
that precedes the HI C022 composite(s) containing the LOINC. If the
original request contained more than six diagnosis codes and you are
using LOINC to request additional information for each of these
diagnosis codes or if you need to specify multiple questions/LOINC
codes per diagnosis you cannot exceed the limit of 12 occurrences of
the C022 composite.
Text Revised
008
100
6
2. It is recommended that the UMO retain the diagnosis information
carried on the request for use in subsequent health care service
review inquiries and notifications related to the original request.
New
010
100 Note 3. Added
5
3. The UMO can use each occurrence of the Health Care Code
Information composite (C022) to specify codes that identify the
specific information that the UMO requires from the provider to
complete the medical review. In the C022 composite, data elements
1270 and 1271 support the use of codes supplied from the Logical
Observation Identifier Names and Codes (LOINC®) List. These codes
identify high-level health care information groupings, specific data
elements, and associated modifiers.
The Logical Observation Identifier Names and Codes (LOINC®) code
set was intended to increase the functionality of the 278 transaction
set and it is not mandated by HIPAA and is only used when mutually
agreed to by trading partners.
Refer to Section 2.2.5 of this guide for more information on requesting
additional information in the 278 response.
Example: HI✽BF:41090~
010
100
1
STANDARD
HI Health Care Information Codes
Level: Detail
Position: 080
Loop: HL
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the delivery of health care
OCTOBER 2002
Original Page Number 253 Dated May 2000
111
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DIAGRAM
HI01
HI ✽
C022
Health Care
Code Info.
HI02
✽
M
HI07
✽
C022
Health Care
Code Info.
HI03
✽
O
C022
Health Care
Code Info.
✽
HI04
✽
O
HI08
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
✽
HI05
✽
O
HI09
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
HI10
✽
O
C022
Health Care
Code Info.
HI06
✽
O
C022
Health Care
Code Info.
HI11
✽
O
C022
Health Care
Code Info.
O
C022
Health Care
Code Info.
HI12
✽
O
C022
Health Care
Code Info.
~
O
ELEMENT SUMMARY
REF.
DES.
USAGE
REQUIRED
HI01
DATA
ELEMENT
C022
NAME
ATTRIBUTES
HEALTH CARE CODE INFORMATION
M
To send health care codes and their associated dates, amounts and quantities
ALIAS: Diagnosis
1082
REQUIRED
HI01 - 1
1270
1
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BJ
Admitting Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BK
Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI01 - 2
1271
Industry Code
M
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
112
Original Page Numbers 253 and 254 Dated May 2000
Code
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI01 - 3
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
1250
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI01 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI01 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI01 - 6
380
Quantity
O
R
1/15
NOT USED
HI01 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI02
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1083
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI02 - 1
1270
2
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BJ
Admitting Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI02 - 2
1271
Industry Code
M
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
OCTOBER 2002
Code
Original Page Number 254 Dated May 2000
113
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI02 - 3
1250
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI02 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI02 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI02 - 6
380
Quantity
O
R
1/15
NOT USED
HI02 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI03
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1084
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI03 - 1
1270
3
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI03 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI03 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
114
Original Page Number 255 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI03 - 4
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI03 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI03 - 6
380
Quantity
O
R
1/15
NOT USED
HI03 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI04
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1191
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI04 - 1
1270
4
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI04 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI04 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI04 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI04 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI04 - 6
380
Quantity
O
R
1/15
OCTOBER 2002
Original Page Numbers 255 and 256 Dated May 2000
115
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
NOT USED
HI04 - 7
SITUATIONAL
HI05
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
799
C022
Version Identifier
O
HEALTH CARE CODE INFORMATION
AN
1/30
O
To send health care codes and their associated dates, amounts and quantities
1192
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI05 - 1
1270
5
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI05 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI05 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI05 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI05 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI05 - 6
380
Quantity
O
R
1/15
NOT USED
HI05 - 7
799
Version Identifier
O
AN
1/30
116
Original Page Numbers 256 and 257 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI06
C022
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1193
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI06 - 1
1270
6
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
LOI
New Code Added
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI06 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI06 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI06 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI06 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI06 - 6
380
Quantity
O
R
1/15
NOT USED
HI06 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI07
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1194
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
7
Original Page Numbers 257 and 258 Dated May 2000
117
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI07 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI07 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI07 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI07 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI07 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI07 - 6
380
Quantity
O
R
1/15
NOT USED
HI07 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI08
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1195
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
118
Original Page Number 258 Dated May 2000
8
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI08 - 1
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI08 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI08 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI08 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI08 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI08 - 6
380
Quantity
O
R
1/15
NOT USED
HI08 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI09
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1196
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
9
Original Page Number 258 and 259 Dated May 2000
119
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI09 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
LOI
New Code Added
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI09 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI09 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI09 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI09 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI09 - 6
380
Quantity
O
R
1/15
NOT USED
HI09 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI10
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1197
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
120
10
Original Page Numbers 259 and 260 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI10 - 1
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
LOI
New Code Added
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI10 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI10 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI10 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI10 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI10 - 6
380
Quantity
O
R
1/15
NOT USED
HI10 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI11
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1198
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
11
Original Page Number 260 Dated May 2000
121
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI11 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
LOI
New Code Added
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI11 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI11 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI11 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI11 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI11 - 6
380
Quantity
O
R
1/15
NOT USED
HI11 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI12
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1199
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
122
12
Original Page Numbers 260 and 261 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI12 - 1
004010X094A1 • 278 • 2000C • HI
SUBSCRIBER DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI12 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI12 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI12 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI12 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI12 - 6
380
Quantity
O
R
1/15
NOT USED
HI12 - 7
799
Version Identifier
O
AN
1/30
OCTOBER 2002
Original Page Number 261 Dated May 2000
123
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
PAPERWORK
PWK
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2000C
• PWK
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
Loop: 2000C — SUBSCRIBER LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
010
100
7
1. This PWK segment is used only if the subscriber is the patient.
010
100
8
2. The UMO can use this PWK segment on the response to request
additional patient information. If the UMO has pended the decision on
this health care services review request (HCR01 = A4) because
additional medical necessity information is required (HCR03 = 90), the
UMO can use this segment to identify the type of documentation
needed such as forms that the provider must complete. The UMO can
also indicate what medium it has used to send these forms.
010
100
9
3. Paperwork requested at the patient level should apply to the patient
event and/or all the services requested. Use the PWK segment in the
appropriate Service loop if requesting medical necessity information
for a specific service.
011
100
0
4. This PWK segment is required to identify requests for specific data
that are sent electronically (PWK02 = EL) but are transmitted in
another X12 functional group rather than by paper or using LOINC in
the HI segments of the response. PWK06 is used to identify the
attached electronic questionnaire. The number in PWK06 should be
referenced in the corresponding electronic attachment.
011
100
1
5. This PWK segment should not be used if
a. the requester should have provided the information within the 278
request (ST-SE) but failed to do so. In this case the UMO should use
the AAA segments in the 278 response to indicate the data that is
missing or invalid.
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to a specific service identified in Loop
2000F and not to all the services requested.
Refer to Section 2.2.5 for more information on using this segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
011
100
2
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
124
New Page inserted after page 261 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
DIAGRAM
PWK01
PWK
755
PWK02
✽ Report Type ✽
Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
756
PWK03
757
PWK04
Report
Report
✽
✽
Copies Need
Transm Code
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
ID
O
ID
PWK05
2/3
66
ID Code
Qualifier
✽
X
ID
PWK06
1/2
67
ID
Code
✽
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000113
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000114
59
OCTOBER 2002
Report Type Code
Benefit Letter
New Page inserted after page 261 dated May 2000
125
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000115
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000116
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000117
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000118
126
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
New Page inserted after page 261 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
PWK02
756
New Segment Added
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
1000119
OCTOBER 2002
Transmission Code
DEFINITION
BM
By Mail
EL
Electronically Only
Use to indicate that attachment is being transmitted
in a separate X12 functional group.
New Page inserted after page 261 dated May 2000
127
004010X094A1 • 278 • 2000C • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
EM
E-Mail
FX
By Fax
VO
Voice
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Use this for voicemail or phone communication.
1000120
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “VO”.
1000121
CODE
AC
SITUATIONAL
PWK06
67
DEFINITION
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
Required if PWK02 equals BM, EL, EM or FX.
1000122
SITUATIONAL
Control Number
P0506
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
ADVISORY: Under
Description
most circumstances, this element is not sent.
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000123
NOT USED
PWK08
C002
ACTIONS INDICATED
ADVISORY: Under
NOT USED
128
PWK09
1525
O
most circumstances, this composite is not sent.
Request Category Code
New Page inserted after page 261 dated May 2000
O
ID
1/2
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
004010X094A1
SUBSCRIBER NAME
• 278 • 2010CA • NM1
IMPLEMENTATION
SUBSCRIBER NAME
Loop: 2010CA — SUBSCRIBER NAME Repeat: 1
Loop ID Changed
Usage: REQUIRED
Repeat: 1
Example: NM1✽IL✽1✽SMITH✽JOE✽✽✽✽MI✽12345678901~
8
102
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
DIAGRAM
NM101
NM1 ✽
98
Entity ID
Code
M
ID
NM107
O
✽
2/3
ID
ID
✽
1035
Name Last/
Org Name
O
66
ID Code
Qualifier
X
NM103
1/1
NM108
✽
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
NM102
NM109
X
O
67
ID
Code
ID
O
706
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
AN 2/80
1036
Name
First
✽
AN 1/35
✽
1/2
NM104
AN 1/25
2/2
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
NM111
✽
NM106
~
2/3
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
IL
REQUIRED
NM102
1065
DEFINITION
Insured or Subscriber
Entity Type Qualifier
M
ID
1/1
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
OCTOBER 2002
DEFINITION
Person
Original Page Number 262 Dated May 2000
129
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
SITUATIONAL
NM103
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
1035
Name Last or Organization Name
O
AN
1/35
O
AN
1/25
O
AN
1/25
Individual last name or organizational name
INDUSTRY: Subscriber
Required if valued on the request.
1273
SITUATIONAL
Last Name
NM104
1036
Name First
Individual first name
INDUSTRY: Subscriber
Required if valued on the request.
1273
SITUATIONAL
First Name
NM105
1037
Name Middle
Individual middle name or initial
INDUSTRY: Subscriber
Middle Name
Use if NM104 is valued and the middle name/initial of the
subscriber is known.
1281
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Subscriber
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1234
REQUIRED
Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0809
CODE
MI
Member Identification Number
The code MI is intended to be the subscriber’s
identification number as assigned by the payer.
Payers use different terminology to convey the
same number. Use MI - Member Identification
Number to convey the following terms: Insured’s ID,
Subscriber’s ID, Health Insurance Claim Number
(HIC), etc.
1444
ZZ
Mutually Defined
The value “ZZ”, when used in this data element,
shall be defined as “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.
1282
REQUIRED
DEFINITION
NM109
67
Identification Code
X
AN
2/80
X
ID
2/2
Code identifying a party or other code
INDUSTRY: Subscriber
ALIAS: Subscriber
SYNTAX:
NOT USED
NM110
706
Primary Identifier
Member Number
P0809
Entity Relationship Code
130 Original Page Number 263 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
NOT USED
OCTOBER 2002
NM111
98
004010X094A1 • 278 • 2010CA • NM1
SUBSCRIBER NAME
Loop ID Changed
Entity Identifier Code
O
ID
Original Page Number 264 Dated May 2000
2/3
131
004010X094A1 • 278 • 2010CA • REF
SUBSCRIBER SUPPLEMENTAL IDENTIFICATION
REFERENCE IDENTIFICATION
REF
004010X094A1SUPPLEMENTAL
SUBSCRIBER
REF
• 278 • 2010CA • IDENTIFICATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
SUBSCRIBER SUPPLEMENTAL
IDENTIFICATION
Loop: 2010CA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 9
Notes:
3
128
1. Use this segment when needed to provide a supplemental identifier
for the subscriber. The primary identifier is the Member Identification
Number in the NM1 segment.
4
128
2. Health Insurance Claim (HIC) Number or Medicaid Recipient
Identification Numbers are to be provided in the NM1 segment as a
Member Identification Number when it is the primary number a UMO
knows a member by (such as for Medicare or Medicaid). Do not use
this segment for the Health Insurance Claim (HIC) Number or Medicaid
Recipient Identification Number unless they are different from the
Member Identification Number provided in the NM1 segment.
4
138
3. If the requester valued this segment with the Patient Account Number
( REF01 = “EJ”) on the request, the UMO must return the same value
in this segment on the response.
Example: REF✽SY✽123456789~
9
102
STANDARD
REF Reference Identification
Level: Detail
Position: 180
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
M
132
128
Reference
Ident Qual
ID
2/3
REF02
127
Reference
Ident
✽
X
AN 1/30
REF03
✽
352
Description
X
Original Page Number 265 Dated May 2000
AN 1/80
REF04
✽
C040
Reference
Identifier
~
O
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010CA • REF
SUBSCRIBER SUPPLEMENTAL IDENTIFICATION
Loop ID Changed
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
REF01
DATA
ELEMENT
128
NAME
ATTRIBUTES
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
1L
Group or Policy Number
Use this code only if you cannot determine if the
number is a Group Number (6P) or a Policy Number
(IG).
1445
1W
Member Identification Number
Do not use if NM108 = MI.
1286
6P
Group Number
A6
Employee Identification Number
EJ
Patient Account Number
F6
Health Insurance Claim (HIC) Number
Use the NM1 (Subscriber Name) segment if the
subscriber’s HIC number is the primary identifier for
his or her coverage. Use this code only in a REF
segment when the payer has a different member
number, and there also is a need to pass the
dependent’s HIC number. This might occur in a
Medicare HMO situation.
1446
HJ
Identity Card Number
Use this code when the Identity Card Number differs
from the Member Identification Number. This is
particularly prevalent in the Medicaid environment.
1285
IG
Insurance Policy Number
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number
SY
Social Security Number
Use this code only if the Social Security Number is
not the primary identifier for the subscriber. The
social security number may not be used for
Medicare.
1000087
REQUIRED
DEFINITION
REF02
127
Reference Identification
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Subscriber
SYNTAX:
Supplemental Identifier
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
Original Page Number 266 Dated May 2000
1/80
133
004010X094A1 • 278 • 2010CA • AAA
SUBSCRIBER REQUEST VALIDATION
REQUEST VALIDATION
AAA
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
004010X094A1REQUEST
SUBSCRIBER
VALIDATION
• 278 • 2010CA
• AAA
IMPLEMENTATION
SUBSCRIBER REQUEST VALIDATION
Loop: 2010CA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 9
Notes:
8
144
1. Required only if the request is not valid at this level.
Example: AAA✽N✽✽67~
0
105
STANDARD
AAA Request Validation
Level: Detail
Position: 230
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify the validity of the request and indicate follow-up action authorized
DIAGRAM
AAA01
AAA
1073
✽ Yes/No Cond ✽
Resp Code
M
ID
1/1
AAA02
559
Agency
Qual Code
O
ID
AAA03
901
AAA04
Reject
✽
✽
Reason Code
2/2
O
ID
2/2
889
Follow-up
Act Code
O
ID
~
1/1
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
AAA01
DATA
ELEMENT
1073
NAME
ATTRIBUTES
Yes/No Condition or Response Code
M
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Valid
Request Indicator
AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.
SEMANTIC:
CODE
NOT USED
134
AAA02
559
DEFINITION
N
No
Y
Yes
Agency Qualifier Code
Original Page Number 267 Dated May 2000
O
ID
2/2
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
AAA03
901
004010X094A1 • 278 • 2010CA • AAA
SUBSCRIBER REQUEST VALIDATION
Reject Reason Code
Loop ID Changed
O
ID
2/2
Code assigned by issuer to identify reason for rejection
Required if AAA01 = “N”.
1242
CODE
15
Required application data missing
Use when data is missing that is not covered by
another Reject Reason Code. Use to indicate that
there is not enough data to identify the subscriber.
1000099
58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the
Patient on the Database
72
Invalid/Missing Subscriber/Insured ID
73
Invalid/Missing Subscriber/Insured Name
74
Invalid/Missing Subscriber/Insured Gender Code
75
Subscriber/Insured Not Found
76
Duplicate Subscriber/Insured ID Number
77
Subscriber Found, Patient Not Found
78
Subscriber/Insured Not in Group/Plan Identified
79
Invalid Participant Identification
Use for invalid/missing subscriber supplemental
identifier.
1288
95
SITUATIONAL
DEFINITION
AAA04
889
Patient Not Eligible
Follow-up Action Code
O
ID
1/1
Code identifying follow-up actions allowed
1447
Required if AAA03 is present and indicates that the rejection is due
to invalid or missing subscriber or patient data.
CODE
OCTOBER 2002
DEFINITION
C
Please Correct and Resubmit
N
Resubmission Not Allowed
Original Page Number 268 Dated May 2000
135
004010X094A1 • 278 • 2010CA • DMG
SUBSCRIBER DEMOGRAPHIC INFORMATION
DEMOGRAPHIC INFORMATION
DMG
004010X094A1DEMOGRAPHIC
SUBSCRIBER
DMG
• 278 • 2010CA •INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
SUBSCRIBER DEMOGRAPHIC INFORMATION
Loop: 2010CA — SUBSCRIBER NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
9
128
1. Use this segment to convey birth date or gender demographic
information about the subscriber.
2. Required if the information is available in the UMO’s database unless
a rejection response was generated and the elements were not valued
on the request.
008
100
8
Example: DMG✽D8✽19580322✽M~
0
103
STANDARD
DMG Demographic Information
Level: Detail
Position: 250
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
Syntax:
1. P0102
If either DMG01 or DMG02 is present, then the other is required.
DIAGRAM
DMG01
DMG ✽
1250
Date Time
format Qual
X
ID
O
ID
✽
X
26
DMG08
Country
Code
2/3
✽
1251
Date Time
Period
2/3
DMG07
✽
DMG02
ID
1068
Gender
Code
✽
AN 1/35
O
659
Basis of
Verif Code
O
DMG03
ID
DMG09
1/2
O
R
1067
DMG05
1109
DMG06
1066
Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1
O
ID
1/1
O
ID
1/1
O
ID
1/2
380
Quantity
✽
DMG04
~
1/15
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
DMG01
DATA
ELEMENT
1250
NAME
ATTRIBUTES
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
SYNTAX:
P0102
CODE
D8
136
Original Page Number 269 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
DMG02
1251
004010X094A1 • 278 • 2010CA • DMG
SUBSCRIBER DEMOGRAPHIC INFORMATION
Loop ID Changed X
Date Time Period
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Subscriber
SYNTAX:
P0102
SEMANTIC:
SITUATIONAL
DMG03
1068
Birth Date
DMG02 is the date of birth.
Gender Code
O
ID
1/1
Code indicating the sex of the individual
INDUSTRY: Subscriber
Gender Code
Required if valued on the request.
1273
CODE
DEFINITION
F
Female
M
Male
U
Unknown
NOT USED
DMG04
1067
Marital Status Code
O
ID
1/1
NOT USED
DMG05
1109
Race or Ethnicity Code
O
ID
1/1
NOT USED
DMG06
1066
Citizenship Status Code
O
ID
1/2
NOT USED
DMG07
26
Country Code
O
ID
2/3
NOT USED
DMG08
659
Basis of Verification Code
O
ID
1/2
NOT USED
DMG09
380
Quantity
O
R
1/15
OCTOBER 2002
Original Page Number 270 Dated May 2000
137
004010X094A1 • 278 • 2010CB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
New Loop Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL PATIENT
INFORMATION
• 278 • 2010CB
• NM1 CONTACT NAME
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT NAME
Loop: 2010CB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
012
100
6
1. Use this NM1 loop to identify the destination location to route the
response for the requested additional patient information.
012
100
8
2. Use this NM1 loop only if
a. the subscriber is the patient
b. the response contains a request for additional patient information
in loop 2000C
c. the destination for the response to the request for additional patient
information differs from the information specified in the UMO Name
NM1 loop (Loop 2010A)
d. the request for additional patient information is not transmitted in
another X12 functional group
012
100
9
3. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.
Refer to Section 2.2.5 for more information on this NM1 loop.
Example: NM1✽2B✽2✽ACME THIRD PARTY ADMINISTRATOR~
012
100
5
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
138
New Page inserted after page 270 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
004010X094A1 • 278 • 2010CB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
DIAGRAM
NM101
NM1 ✽
98
Entity ID
Code
M
ID
NM107
O
✽
2/3
ID
ID
✽
66
NM109
NM104
X
O
67
ID
Code
X
ID
O
706
1037
Name
Middle
✽
Entity
Relat Code
✽
NM105
AN 1/25
NM110
AN 2/80
1036
Name
First
✽
AN 1/35
✽
1/2
1035
Name Last/
Org Name
O
ID Code
Qualifier
X
NM103
1/1
NM108
✽
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
NM102
O
ID
O
AN 1/10
98
Entity ID
Code
✽
1038
Name
Prefix
✽
AN 1/25
NM111
2/2
NM106
~
2/3
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
1P
Provider
2B
Third-Party Administrator
ABG
Organization
Use when the destination is an entity other than
those listed.
1000130
REQUIRED
DEFINITION
NM102
1065
FA
Facility
PR
Payer
X3
Utilization Management Organization
Entity Type Qualifier
M
ID
1/1
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
Person
Use this name only if the destination is an
individual, such as an individual primary care
physician.
1000131
2
SITUATIONAL
DEFINITION
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
AN
1/35
Individual last name or organizational name
INDUSTRY: Response
1000132
OCTOBER 2002
Contact Last or Organization Name
Required if the responder needs to identify the destination by name.
New Page inserted after page 270 dated May 2000
139
New
004010X094A1 • 278 • 2010CB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
SITUATIONAL
NM104
1036
Segment Added ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Name First
O
AN
1/25
Individual first name
INDUSTRY: Response
Use if NM103 is valued and the destination is an individual (NM102
= 1), such as a primary care provider.
1000133
SITUATIONAL
Contact First Name
NM105
1037
Name Middle
O
AN
1/25
Individual middle name or initial
INDUSTRY: Response
Contact Middle Name
Use if NM104 is present and the middle name/initial of the person is
known.
1233
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Response
Contact Name Suffix
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1234
SITUATIONAL
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
1000134
P0809
Required if the responder needs to use an identifier to identify the
destination.
CODE
DEFINITION
24
Employer’s Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification
Use until the National PlanID is mandated if the
destination is a payer.
1000135
XV
Health Care Financing Administration National
PlanID
Required if the National PlanID is mandated for use.
Otherwise, one of the other listed codes may be
used.
Use if the destination is a payer.
1000136
CODE SOURCE 540: Health Care Financing Administration
National PlanID
XX
1000137
140
Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Use if the destination is a provider.
New Page inserted after page 270 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
NM109
67
New Segment Added
004010X094A1 • 278 • 2010CB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Response
SYNTAX:
Contact Identifier
P0809
Required if NM108 is used.
1000138
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
OCTOBER 2002
New Page inserted after page 270 dated May 2000 141
New
004010X094A1 • 278 • 2010CB • N3
ADDITIONAL PATIENT INFORMATION CONTACT ADDRESS
ADDRESS INFORMATION
N3
Segment Added ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2010CB
• N3 CONTACT ADDRESS
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT ADDRESS
Loop: 2010CB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
014
100
1
1. This segment identifies the office location to route the response to the
request for additional patient information.
014
100
2
2. Use this segment only if the subscriber is the patient and the
response to the request for additional patient information must be
routed to a specific office location.
014
100
3
3. Do not use if the request for additional patient information is in
another X12 functional group.
Example: N3✽43 SUNRISE BLVD✽SUITE 1000~
014
100
0
STANDARD
N3 Address Information
Level: Detail
Position: 200
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the location of the named party
DIAGRAM
N301
N3 ✽
166
Address
Information
M
AN 1/55
N302
✽
166
Address
Information
O
~
AN 1/55
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
N301
DATA
ELEMENT
166
NAME
ATTRIBUTES
Address Information
M
AN
1/55
Address information
INDUSTRY: Response
Use this element for the first line of the requester’s address.
1000144
SITUATIONAL
Contact Address Line
N302
166
Address Information
O
AN
1/55
Address information
INDUSTRY: Response
1453
142
Contact Address Line
Required only if a second address line exists.
New Page inserted after page 270 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
GEOGRAPHIC LOCATION
N4
004010X094A1 • 278 • 2010CB • N4
ADDITIONAL PATIENT INFORMATION CONTACT CITY/STATE/ZIP CODE
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2010CB
• N4 CONTACT CITY/STATE/ZIP CODE
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT CITY/STATE/ZIP CODE
Loop: 2010CB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
014
100
1
1. This segment identifies the office location to route the response to the
request for additional patient information.
014
100
2
2. Use this segment only if the subscriber is the patient and the
response to the request for additional patient information must be
routed to a specific office location.
014
100
3
3. Do not use if the request for additional patient information is in
another X12 functional group.
Example: N4✽MIAMI✽FL✽33131✽✽DP✽UTILIZATION REVIEW DEPT~
014
100
6
STANDARD
N4 Geographic Location
Level: Detail
Position: 210
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax:
1. C0605
If N406 is present, then N405 is required.
DIAGRAM
N401
N4 ✽
19
City
Name
O
N402
✽
AN 2/30
156
State or
Prov Code
O
ID
N403
✽
2/2
116
Postal
Code
O
ID
3/15
N404
26
Country
Code
✽
O
ID
N405
✽
2/3
309
Location
Qualifier
X
ID
N406
✽
1/2
310
Location
Identifier
O
~
AN 1/30
ELEMENT SUMMARY
USAGE
SITUATIONAL
REF.
DES.
N401
DATA
ELEMENT
19
NAME
ATTRIBUTES
City Name
O
AN
2/30
Free-form text for city name
INDUSTRY: Response
Contact City Name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.
1000147
OCTOBER 2002
Use when necessary to provide this data as part of the response
contact location identification.
New Page inserted after page 270 dated May 2000 143
New Segment Added
004010X094A1 • 278 • 2010CB • N4
ADDITIONAL PATIENT INFORMATION CONTACT CITY/STATE/ZIP CODE
SITUATIONAL
N402
156
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
State or Province Code
O
ID
2/2
Code (Standard State/Province) as defined by appropriate government agency
INDUSTRY: Response
COMMENT:
N402 is required only if city name (N401) is in the U.S. or Canada.
CODE SOURCE 22:
States and Outlying Areas of the U.S.
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact State or Province Code
N403
116
Postal Code
O
ID
3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
INDUSTRY: Response
CODE SOURCE 51:
ZIP Code
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact Postal Zone or ZIP Code
N404
26
Country Code
O
ID
2/3
X
ID
1/2
O
AN
1/30
Code identifying the country
INDUSTRY: Response
CODE SOURCE 5:
Contact Country Code
Countries, Currencies and Funds
Use only if the address is out of the U.S.
1317
SITUATIONAL
N405
309
Location Qualifier
Code identifying type of location
SYNTAX:
C0605
Required if N406 is valued.
1000148
CODE
SITUATIONAL
N406
310
DEFINITION
B1
Branch
DP
Department
Location Identifier
Code which identifies a specific location
INDUSTRY: Response
SYNTAX:
Contact Specific Location
C0605
1000149
Required if N405 is valued.
1000150
Value this field if the response to the request for additional
information must be directed to a particular domain.
144
New Page inserted after page 270 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ADMINISTRATIVE COMMUNICATIONS CONTACT
PER
New Segment Added
004010X094A1 • 278 • 2010CB • PER
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
ADDITIONAL
004010X094A1
PATIENT
INFORMATION
• 278 • 2010CB
• PER CONTACT INFORMATION
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT INFORMATION
Loop: 2010CB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
015
100
3
1. Required if the provider must direct the response to the request for
additional patient information to a specific requester contact,
electronic mail, facsimile, or phone number other than the contact
provided in the PER segment in the UMO Name loop (Loop 2010A)
PER segment of this 278 response.
015
100
5
2. Use this segment only if the subscriber is the patient.
014
100
3
3. Do not use if the request for additional patient information is in
another X12 functional group.
4
143
4. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.
5
143
5. By definition of the standard, if PER03 is used, PER04 is required.
Example: PER✽IC✽MARY✽FX✽3135554321~
015
100
2
STANDARD
PER Administrative Communications Contact
Level: Detail
Position: 220
Loop: HL/NM1
Requirement: Optional
Max Use: 3
Purpose: To identify a person or office to whom administrative communications should be
directed
Syntax:
1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
OCTOBER 2002
New Page inserted after page 270 dated May 2000
145
New Segment Added
004010X094A1 • 278 • 2010CB • PER
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DIAGRAM
PER01
PER ✽
366
Contact
Funct Code
M
ID
PER07
PER02
✽
2/2
O
365
PER08
Comm
✽
✽
Number Qual
X
ID
2/2
93
Name
PER03
AN 1/60
X
364
Comm
Number
X
365
PER04
Comm
✽
✽
Number Qual
ID
PER09
2/2
✽
O
X
AN 1/80
PER05
365
PER06
Comm
✽
✽
Number Qual
X
ID
2/2
364
Comm
Number
X
AN 1/80
443
Contact Inq
Reference
AN 1/80
364
Comm
Number
~
AN 1/20
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PER01
DATA
ELEMENT
366
NAME
ATTRIBUTES
Contact Function Code
M
ID
2/2
Code identifying the major duty or responsibility of the person or group named
CODE
IC
SITUATIONAL
PER02
93
DEFINITION
Information Contact
Name
O
AN
1/60
Free-form name
INDUSTRY: Response
Contact Name
1000156
Used only when response must be directed to a particular contact.
1433
Use this data element when the name of the individual to contact is
not already defined or is different than the name within the prior
name segment (e.g. N1 or NM1).
SITUATIONAL
PER03
365
Communication Number Qualifier
X
ID
2/2
Code identifying the type of communication number
SYNTAX:
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
1473
CODE
SITUATIONAL
PER04
364
DEFINITION
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Communication Number
X
AN
1/80
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
1473
146
Contact Communication Number
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
New Page inserted after page 270 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
PER05
365
004010X094A1 • 278 • 2010CB • PER
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER06
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
SITUATIONAL
Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER08
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
OCTOBER 2002
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
NOT USED
Contact Communication Number
PER09
443
Contact Inquiry Reference
O
AN
New Page inserted after page 270 dated May 2000
1/20
147
004010X094A1 • 278 • 2000D • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
PATIENT
EVENT
TRACKING
• 278
• 2000DNUMBER
• TRN
IMPLEMENTATION
PATIENT EVENT TRACKING NUMBER
Loop: 2000D — DEPENDENT LEVEL
Usage: SITUATIONAL
Repeat: 3
Notes:
6
132
1. Any trace numbers provided at this level on the request must be
returned by the UMO at this level of the 278 response.
010
100
4
2. The UMO can assign a trace number to this patient event for tracking
purposes.
8
138
3. If the 278 request 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 should merely pass all TRN segments
received in the 278 request in the 278 response transaction.
4. 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.
9
138
Example: TRN✽2✽2001042801✽9012345678✽CARDIOLOGY~
010
100
3
STANDARD
TRN Trace
Level: Detail
Position: 020
Loop: HL
Requirement: Optional
Max Use: 9
Purpose: To uniquely identify a transaction to an application
148
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OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000D • TRN
PATIENT EVENT TRACKING NUMBER
New Segment Added
DIAGRAM
TRN01
TRN ✽
481
Trace Type
Code
M
ID
1/2
TRN02
✽
127
Reference
Ident
M
TRN03
509
TRN04
✽ Originating ✽
Company ID
AN 1/30
O
AN 10/10
127
Reference
Ident
O
~
AN 1/30
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
TRN01
DATA
ELEMENT
481
NAME
ATTRIBUTES
Trace Type Code
M
ID
1/2
Code identifying which transaction is being referenced
CODE
DEFINITION
1
Current Transaction Trace Numbers
The term “Current Transaction Trace Number”
refers to the trace number assigned by the creator
of the 278 response transaction (the UMO).
1328
2
Referenced Transaction Trace Numbers
The term “Referenced Transaction Trace Number”
refers to the trace number originally sent in the 278
request transaction.
1329
REQUIRED
TRN02
127
Reference Identification
M
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Patient
SEMANTIC:
REQUIRED
TRN03
509
Event Tracking Number
TRN02 provides unique identification for the transaction.
Originating Company Identifier
O
AN
10/10
A unique identifier designating the company initiating the funds transfer
instructions. The first character is one-digit ANSI identification code designation
(ICD) followed by the nine-digit identification number which may be an IRS
employer identification number (EIN), data universal numbering system (DUNS),
or a user assigned number; the ICD for an EIN is 1, DUNS is 3, user assigned
number is 9
INDUSTRY: Trace
SEMANTIC:
Assigning Entity Identifier
TRN03 identifies an organization.
1248
Use this element to identify the organization that assigned this
trace number. If TRN01 is “2", this is the value received in the
original 278 request transaction. If TRN01 is ”1", use this
information to identify the UMO organization that assigned this
trace number.
1249
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.
OCTOBER 2002
New Page inserted after page 272 dated May 2000
149
004010X094A1 • 278 • 2000D • TRN
PATIENT EVENT TRACKING NUMBER
SITUATIONAL
TRN04
127
New Segment Added
Reference Identification
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
O
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Trace
SEMANTIC:
1250
150
Assigning Entity Additional Identifier
TRN04 identifies a further subdivision within the organization.
Use this information if necessary to further identify a specific
component, such as a specific division or group, of the company
identified in the previous data element (TRN03).
New Page inserted after page 272 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
004010X094A1DIAGNOSIS
DEPENDENT
• 278 • 2000D • HI
IMPLEMENTATION
DEPENDENT DIAGNOSIS
Loop: 2000D — DEPENDENT LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:
7
147
1. Required if valued on the request and used by the UMO to render a
decision. If the response has not been rendered and this segment is
used to request additional information associated with a specific
diagnosis, place the specific diagnosis code in the HI C022 composite
that precedes the HI C022 composite(s) containing the LOINC. If the
original request contained more than six diagnosis codes and you are
using LOINC to request additional information for each of these
diagnosis codes or if you need to specify multiple questions/LOINC
codes per diagnosis you cannot exceed the limit of 12 occurrences of
the C022 composite.
Text Revised
008
100
6
2. It is recommended that the UMO retain the diagnosis information
carried on the request for use in subsequent health care service
review inquiries and notifications related to the original request.
New Note 3. Added
010
100
5
3. The UMO can use each occurrence of the Health Care Code
Information composite (C022) to specify codes that identify the
specific information that the UMO requires from the provider to
complete the medical review. In the C022 composite, data elements
1270 and 1271 support the use of codes supplied from the Logical
Observation Identifier Names and Codes (LOINC®) List. These codes
identify high-level health care information groupings, specific data
elements, and associated modifiers.
The Logical Observation Identifier Names and Codes (LOINC®) code
set was intended to increase the functionality of the 278 transaction
set and it is not mandated by HIPAA and is only used when mutually
agreed to by trading partners.
Refer to Section 2.2.5 of this guide for more information on requesting
additional information in the 278 response.
Example: HI✽BF:41090~
010
100
1
STANDARD
HI Health Care Information Codes
Level: Detail
Position: 080
Loop: HL
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the delivery of health care
OCTOBER 2002
Original Page Number 279 Dated May 2000
151
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DIAGRAM
HI01
HI ✽
C022
Health Care
Code Info.
HI02
✽
M
HI03
✽
O
HI07
✽
C022
Health Care
Code Info.
C022
Health Care
Code Info.
✽
HI04
✽
O
HI08
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
✽
HI05
✽
O
HI09
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
HI10
✽
O
C022
Health Care
Code Info.
HI06
✽
O
C022
Health Care
Code Info.
HI11
✽
O
C022
Health Care
Code Info.
O
C022
Health Care
Code Info.
HI12
✽
O
C022
Health Care
Code Info.
~
O
ELEMENT SUMMARY
REF.
DES.
USAGE
REQUIRED
HI01
DATA
ELEMENT
C022
NAME
ATTRIBUTES
HEALTH CARE CODE INFORMATION
M
To send health care codes and their associated dates, amounts and quantities
ALIAS: Diagnosis
1106
REQUIRED
HI01 - 1
1270
1
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BJ
Admitting Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BK
Principal Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Added
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI01 - 2
1271
Industry Code
M
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
152
Original Page Numbers 279 and 280 Dated May 2000
Code
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI01 - 3
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
1250
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI01 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI01 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI01 - 6
380
Quantity
O
R
1/15
NOT USED
HI01 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI02
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1107
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI02 - 1
1270
2
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
BJ
Admitting Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI02 - 2
1271
Industry Code
M
AN
1/30
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
OCTOBER 2002
Code
Original Page Number 280 Dated May 2000
153
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI02 - 3
1250
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI02 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI02 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI02 - 6
380
Quantity
O
R
1/15
NOT USED
HI02 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI03
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1108
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI03 - 1
1270
3
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI03 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI03 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
154
Original Page Number 281 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI03 - 4
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI03 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI03 - 6
380
Quantity
O
R
1/15
NOT USED
HI03 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI04
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1191
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI04 - 1
1270
4
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI04 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI04 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI04 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI04 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI04 - 6
380
Quantity
O
R
1/15
OCTOBER 2002
Original Page Numbers 281and 282 Dated May 2000
155
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
NOT USED
HI04 - 7
SITUATIONAL
HI05
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
799
C022
Version Identifier
O
HEALTH CARE CODE INFORMATION
AN
1/30
O
To send health care codes and their associated dates, amounts and quantities
1192
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI05 - 1
1270
5
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI05 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI05 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI05 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI05 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI05 - 6
380
Quantity
O
R
1/15
NOT USED
HI05 - 7
799
Version Identifier
O
AN
1/30
156 Original Page Numbers 282 and 283 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI06
C022
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1193
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
REQUIRED
HI06 - 1
1270
6
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
LOI
New Code Value
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI06 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI06 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI06 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI06 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI06 - 6
380
Quantity
O
R
1/15
NOT USED
HI06 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI07
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1194
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
7
Original Page Numbers 283 and 284 Dated May 2000
157
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI07 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI07 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI07 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI07 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI07 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI07 - 6
380
Quantity
O
R
1/15
NOT USED
HI07 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI08
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1195
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
158
Original Page Number 284 Dated May 2000
8
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI08 - 1
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI08 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI08 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI08 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI08 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI08 - 6
380
Quantity
O
R
1/15
NOT USED
HI08 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI09
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1196
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
9
Original Page Numbers 284 and 285 Dated May 2000 159
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI09 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI09 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI09 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI09 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI09 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI09 - 6
380
Quantity
O
R
1/15
NOT USED
HI09 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI10
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1197
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
160
10
Original Page Numbers 285 and 286 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI10 - 1
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI10 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI10 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI10 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI10 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI10 - 6
380
Quantity
O
R
1/15
NOT USED
HI10 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI11
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1198
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
OCTOBER 2002
11
Original Page Number 286 Dated May 2000
161
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI11 - 1
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI11 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI11 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI11 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI11 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI11 - 6
380
Quantity
O
R
1/15
NOT USED
HI11 - 7
799
Version Identifier
O
AN
1/30
SITUATIONAL
HI12
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1199
ALIAS: Diagnosis
1477
Required if valued on the request and used by the UMO to render a
decision.
162
12
Original Page Numbers 286 and 287 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI12 - 1
004010X094A1 • 278 • 2000D • HI
DEPENDENT DIAGNOSIS
1270
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
INDUSTRY: Diagnosis
CODE
BF
Type Code
DEFINITION
Diagnosis
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
New Code Value
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
REQUIRED
HI12 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Diagnosis
SITUATIONAL
HI12 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
D8
SITUATIONAL
HI12 - 4
1251
DEFINITION
Date Expressed in Format CCYYMMDD
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Diagnosis
Date
Use only when the date diagnosed is known.
1280
NOT USED
HI12 - 5
782
Monetary Amount
O
R
1/18
NOT USED
HI12 - 6
380
Quantity
O
R
1/15
NOT USED
HI12 - 7
799
Version Identifier
O
AN
1/30
OCTOBER 2002
Original Page Number 287 Dated May 2000
163
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
PAPERWORK
PWK
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2000D
• PWK
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
Loop: 2000D — DEPENDENT LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
010
100
8
1. The UMO can use this PWK segment on the response to request
additional patient information. If the UMO has pended the decision on
this health care services review request (HCR01 = A4) because
additional medical necessity information is required (HCR03 = 90), the
UMO can use this segment to identify the type of documentation
needed such as forms that the provider must complete. The UMO can
also indicate what medium it has used to send these forms.
010
100
9
2. Paperwork requested at the patient level should apply to the patient
event and/or all the services requested. Use the PWK segment in the
appropriate Service loop if requesting medical necessity information
for a specific service.
011
100
0
3. This PWK segment is required to identify requests for specific data
that are sent electronically (PWK02 = EL) but are transmitted in
another X12 functional group rather than by paper or using LOINC in
the HI segments of the response. PWK06 is used to identify the
attached electronic questionnaire. The number in PWK06 should be
referenced in the corresponding electronic attachment.
011
100
1
4. This PWK segment should not be used if
a. the requester should have provided the information within the 278
request (ST-SE) but failed to do so. In this case the UMO should use
the AAA segments in the 278 response to indicate the data that is
missing or invalid.
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to a specific service identified in Loop
2000F and not to all the services requested.
Refer to Section 2.2.5 for more information on using this segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
011
100
2
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
164
New Page inserted after page 287 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
DIAGRAM
PWK01
PWK
755
PWK02
✽ Report Type ✽
Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
756
PWK03
757
PWK04
Report
Report
✽
✽
Copies Need
Transm Code
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
ID
O
ID
PWK05
2/3
66
ID Code
Qualifier
✽
X
ID
PWK06
1/2
67
ID
Code
✽
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000113
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000114
59
OCTOBER 2002
Report Type Code
Benefit Letter
New Page inserted after page 287 dated May 2000
165
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000115
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000116
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000117
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000118
166
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
New Page inserted after page 287 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
PWK02
756
New Segment Added
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
1000119
OCTOBER 2002
Transmission Code
DEFINITION
BM
By Mail
EL
Electronically Only
Use to indicate that attachment is being transmitted
in a separate X12 functional group.
New Page inserted after page 287 dated May 2000
167
004010X094A1 • 278 • 2000D • PWK
ADDITIONAL PATIENT INFORMATION
New Segment Added
EM
E-Mail
FX
By Fax
VO
Voice
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Use this for voicemail or phone communication.
1000120
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “VO”.
1000121
CODE
AC
SITUATIONAL
PWK06
67
DEFINITION
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
Required if PWK02 equals BM, EL, EM or FX.
1000122
SITUATIONAL
Control Number
P0506
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
Description
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000123
NOT USED
PWK08
C002
ACTIONS INDICATED
O
NOT USED
PWK09
1525
Request Category Code
O
168 New Page inserted after page 287 dated May 2000
ID
1/2
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
004010X094A1 • 278 • 2010DA • NM1
DEPENDENT NAME
004010X094A1
DEPENDENT NAME
• 278 • 2010DA • NM1
IMPLEMENTATION
DEPENDENT NAME
Loop: 2010DA — DEPENDENT NAME Repeat: 1
Loop ID Changed
Usage: REQUIRED
Repeat: 1
Notes:
1
145
1. Use this segment to convey the name of the dependent who is the
patient.
2. NM108 and NM109 are situational on the response but Not Used on
the request. This enables the UMO to return a unique member ID for
the dependent that was not known to the requester at the time of the
request. Normally, if the dependent has a unique member ID, Loop
2000D is not used.
3
129
Example: NM1✽QC✽1✽SMITH✽MARY~
8
140
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
DIAGRAM
NM101
NM1 ✽
M
ID
NM107
O
NM102
✽
2/3
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
OCTOBER 2002
98
Entity ID
Code
ID
O
66
NM109
ID Code
Qualifier
X
ID
✽
1/2
1035
Name Last/
Org Name
1/1
NM108
✽
NM103
X
O
67
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
X
NM105
AN 1/25
NM110
✽
AN 2/80
1036
Name
First
✽
AN 1/35
ID
Code
✽
NM104
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
AN 1/25
NM111
✽
NM106
~
2/3
Original Page Number 288 Dated May 2000
169
004010X094A1 • 278 • 2010DA • NM1
DEPENDENT NAME
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
QC
REQUIRED
NM102
1065
DEFINITION
Patient
Entity Type Qualifier
M
ID
1/1
O
AN
1/35
O
AN
1/25
O
AN
1/25
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
SITUATIONAL
NM103
1035
DEFINITION
Person
Name Last or Organization Name
Individual last name or organizational name
INDUSTRY: Dependent
Required if valued on the request.
1273
SITUATIONAL
Last Name
NM104
1036
Name First
Individual first name
INDUSTRY: Dependent
Required if valued on the request.
1273
SITUATIONAL
First Name
NM105
1037
Name Middle
Individual middle name or initial
INDUSTRY: Dependent
Middle Name
Use if NM104 is valued and the middle name/initial of the dependent
is known.
1294
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Dependent
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1234
SITUATIONAL
Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0809
CODE
MI
DEFINITION
Member Identification Number
Use this code for the payer-assigned identifier for
the dependent, even if the payer calls its number a
policy number, recipient number, HIC number, or
some other synonym.
1115
ZZ
170 Original Page Number 289 Dated May 2000
Mutually Defined
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
The value “ZZ”, when used in this data element,
shall be defined as “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.
1282
SITUATIONAL
004010X094A1 • 278 • 2010DA • NM1
DEPENDENT NAME
NM109
67
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Dependent
ALIAS: Dependent
SYNTAX:
Primary Identifier
Member Number
P0809
Value only if the dependent has a unique member ID that is known
by the UMO. Under most circumstances, this data element is not
used.
1295
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
OCTOBER 2002
Original Page Number 290 Dated May 2000
171
004010X094A1 • 278 • 2010DA • REF
DEPENDENT SUPPLEMENTAL IDENTIFICATION
REFERENCE IDENTIFICATION
REF
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1SUPPLEMENTAL
DEPENDENT
REF
• 278 • 2010DA •IDENTIFICATION
Loop ID Changed
IMPLEMENTATION
DEPENDENT SUPPLEMENTAL
IDENTIFICATION
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 3
Notes:
6
129
1. Use this segment when necessary to provide supplemental identifiers
for the dependent.
2. If the requester valued this segment with the Patient Account Number
( REF01 = “EJ”) on the request, the UMO must return the same value
in this segment on the response.
4
138
Example: REF✽SY✽123456789~
4
103
STANDARD
REF Reference Identification
Level: Detail
Position: 180
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify identifying information
Syntax:
1. R0203
At least one of REF02 or REF03 is required.
DIAGRAM
REF01
REF ✽
128
Reference
Ident Qual
M
ID
2/3
REF02
127
Reference
Ident
✽
X
REF03
✽
AN 1/30
352
Description
X
AN 1/80
REF04
C040
Reference
Identifier
✽
~
O
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
REF01
DATA
ELEMENT
128
NAME
ATTRIBUTES
Reference Identification Qualifier
M
ID
2/3
Code qualifying the Reference Identification
CODE
A6
Employee Identification Number
EJ
Patient Account Number
SY
Social Security Number
1000089
172
DEFINITION
Original Page Number 291 Dated May 2000
The social security number may not be used for
Medicare.
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
REF02
127
004010X094A1 • 278 • 2010DA • REF
DEPENDENT SUPPLEMENTAL IDENTIFICATION
Reference Identification
Loop ID Changed
X
AN
1/30
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Dependent
SYNTAX:
Supplemental Identifier
R0203
NOT USED
REF03
352
Description
X
NOT USED
REF04
C040
REFERENCE IDENTIFIER
O
OCTOBER 2002
AN
Original Page Number 292 Dated May 2000
1/80
173
004010X094A1 • 278 • 2010DA • AAA
DEPENDENT REQUEST VALIDATION
REQUEST VALIDATION
AAA
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1REQUEST
DEPENDENT
VALIDATION
• 278 • 2010DA
• AAA
Loop ID Changed
IMPLEMENTATION
DEPENDENT REQUEST VALIDATION
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 9
Notes:
1
124
1. Required only if the request is not valid at this level.
Example: AAA✽N✽✽67~
3
105
STANDARD
AAA Request Validation
Level: Detail
Position: 230
Loop: HL/NM1
Requirement: Optional
Max Use: 9
Purpose: To specify the validity of the request and indicate follow-up action authorized
DIAGRAM
AAA01
AAA
1073
✽ Yes/No Cond ✽
Resp Code
M
ID
1/1
AAA02
559
Agency
Qual Code
O
ID
AAA03
901
AAA04
Reject
✽
✽
Reason Code
2/2
O
ID
2/2
889
Follow-up
Act Code
O
ID
~
1/1
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
AAA01
DATA
ELEMENT
1073
NAME
ATTRIBUTES
Yes/No Condition or Response Code
M
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Valid
Request Indicator
AAA01 designates whether the request is valid or invalid. Code “Y”
indicates that the code is valid; code “N” indicates that the code is invalid.
SEMANTIC:
CODE
NOT USED
174
AAA02
559
DEFINITION
N
No
Y
Yes
Agency Qualifier Code
Original Page Number 293 Dated May 2000
O
ID
2/2
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
AAA03
901
004010X094A1 • 278 • 2010DA • AAA
DEPENDENT REQUEST VALIDATION
Reject Reason Code Loop ID Changed
O
ID
2/2
Code assigned by issuer to identify reason for rejection
Required if AAA01 = “N”.
1242
CODE
15
Required application data missing
Use this code to indicate missing dependent
relationship information.
1297
33
Input Errors
Use this code to indicate invalid dependent
relationship information.
1298
SITUATIONAL
DEFINITION
AAA04
889
58
Invalid/Missing Date-of-Birth
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name
66
Invalid/Missing Patient Gender Code
67
Patient Not Found
68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the
Patient on the Database
77
Subscriber Found, Patient Not Found
95
Patient Not Eligible
Follow-up Action Code
O
ID
1/1
Code identifying follow-up actions allowed
1452
Required if AAA03 is present and indicates that the rejection is due
to invalid or missing dependent or patient data.
CODE
OCTOBER 2002
DEFINITION
C
Please Correct and Resubmit
N
Resubmission Not Allowed
Original Page Number 294 Dated May 2000
175
004010X094A1 • 278 • 2010DA • DMG
DEPENDENT DEMOGRAPHIC INFORMATION
DEMOGRAPHIC INFORMATION
DMG
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
004010X094A1DEMOGRAPHIC
DEPENDENT
• 278 • 2010DAINFORMATION
• DMG
IMPLEMENTATION
DEPENDENT DEMOGRAPHIC INFORMATION
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
9
129
1. Use this segment to convey birth date or gender demographic
information about the dependent.
2. Required if the information is available in the UMO’s database unless
a rejection response was generated and the elements were not valued
on the request.
008
100
8
Example: DMG✽D8✽19580322✽M~
5
103
STANDARD
DMG Demographic Information
Level: Detail
Position: 250
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To supply demographic information
Syntax:
1. P0102
If either DMG01 or DMG02 is present, then the other is required.
DIAGRAM
DMG01
DMG ✽
1250
Date Time
format Qual
X
ID
O
ID
✽
X
26
DMG08
Country
Code
2/3
✽
1251
Date Time
Period
2/3
DMG07
✽
DMG02
ID
1068
Gender
Code
✽
AN 1/35
O
659
Basis of
Verif Code
O
DMG03
ID
DMG09
1/2
O
R
1067
DMG05
1109
DMG06
1066
Marital
Race or
✽
✽
✽ Citizenship
Status Code
Ethnic Code
Status Code
1/1
O
ID
1/1
O
ID
1/1
O
ID
1/2
380
Quantity
✽
DMG04
~
1/15
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
DMG01
DATA
ELEMENT
1250
NAME
ATTRIBUTES
Date Time Period Format Qualifier
X
ID
2/3
Code indicating the date format, time format, or date and time format
SYNTAX:
P0102
CODE
D8
176
Original Page Number 295 Dated May 2000
DEFINITION
Date Expressed in Format CCYYMMDD
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
DMG02
1251
004010X094A1 • 278 • 2010DA • DMG
DEPENDENT DEMOGRAPHIC INFORMATION
Loop ID Changed
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Dependent
SYNTAX:
P0102
SEMANTIC:
SITUATIONAL
DMG03
1068
Birth Date
DMG02 is the date of birth.
Gender Code
O
ID
1/1
Code indicating the sex of the individual
INDUSTRY: Dependent
Gender Code
Required if valued on the request.
1273
CODE
DEFINITION
F
Female
M
Male
U
Unknown
NOT USED
DMG04
1067
Marital Status Code
O
ID
1/1
NOT USED
DMG05
1109
Race or Ethnicity Code
O
ID
1/1
NOT USED
DMG06
1066
Citizenship Status Code
O
ID
1/2
NOT USED
DMG07
26
Country Code
O
ID
2/3
NOT USED
DMG08
659
Basis of Verification Code
O
ID
1/2
NOT USED
DMG09
380
Quantity
O
R
1/15
OCTOBER 2002
Original Page Number 296 Dated May 2000
177
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
INSURED BENEFIT
INS
004010X094A1RELATIONSHIP
DEPENDENT
• 278 • 2010DA • INS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Loop ID Changed
IMPLEMENTATION
DEPENDENT RELATIONSHIP
Loop: 2010DA — DEPENDENT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
0
130
1. Use this segment to convey information on the relationship of the
dependent to the insured.
2. Required if the information is available in the UMO’s database unless
a rejection response was generated and the elements were not valued
on the request.
008
100
8
Example: INS✽N✽19~
6
103
STANDARD
INS Insured Benefit
Level: Detail
Position: 260
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To provide benefit information on insured entities
Syntax:
1. P1112
If either INS11 or INS12 is present, then the other is required.
DIAGRAM
INS01
INS
1073
INS02
✽ Yes/No Cond ✽
Resp Code
M
ID
INS07
1/1
M
1219
1069
Individual
Relat Code
ID
INS08
INS03
875
INS04
1203
INS05
2/2
O
584
INS09
ID
3/3
O
1220
ID
INS10
2/3
O
1073
ID
INS13
1/2
1165
Confident
Code
✽
O
O
ID
1/1
ID
INS14
2/2
19
City
Name
✽
O
O
AN 2/30
ID
INS15
✽
1/1
156
State or
Prov Code
O
178 Original Page Number 297 Dated May 2000
O
ID
2/2
ID
1/1
INS16
INS06
O
ID
2/3
1/1
ID
INS17
O
ID
1/1
1251
Date Time
Period
✽
X
AN 1/35
1470
Number
✽
INS12
2/3
1218
Medicare
Plan Code
O
1250
Date Time
format Qual
X
26
Country
Code
✽
ID
INS11
Student
✽ COBRA Qual ✽ Employment ✽
✽ Yes/No Cond ✽
Event Code
Status Code
Status Code
Resp Code
O
1216
Maintain
Benefit
✽ Maintenance ✽
✽
✽
Type Code
Reason Code
Status Code
N0
~
1/9
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
Loop ID Changed
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
INS01
DATA
ELEMENT
1073
NAME
ATTRIBUTES
Yes/No Condition or Response Code
M
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Insured
Indicator
INS01 indicates status of the insured. A “Y” value indicates the insured
is a subscriber: an “N” value indicates the insured is a dependent.
SEMANTIC:
CODE
N
REQUIRED
INS02
1069
DEFINITION
No
Individual Relationship Code
M
ID
2/2
Code indicating the relationship between two individuals or entities
ALIAS: Relationship
CODE
OCTOBER 2002
to Insured
DEFINITION
01
Spouse
04
Grandfather or Grandmother
05
Grandson or Granddaughter
07
Nephew or Niece
09
Adopted Child
10
Foster Child
15
Ward
17
Stepson or Stepdaughter
19
Child
20
Employee
21
Unknown
22
Handicapped Dependent
23
Sponsored Dependent
24
Dependent of a Minor Dependent
29
Significant Other
32
Mother
33
Father
34
Other Adult
39
Organ Donor
40
Cadaver Donor
41
Injured Plaintiff
43
Child Where Insured Has No Financial Responsibility
Original Page Number 298 Dated May 2000
179
004010X094A1 • 278 • 2010DA • INS
DEPENDENT RELATIONSHIP
Loop ID Changed
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
53
Life Partner
G8
Other Relationship
NOT USED
INS03
875
Maintenance Type Code
O
ID
3/3
NOT USED
INS04
1203
Maintenance Reason Code
O
ID
2/3
NOT USED
INS05
1216
Benefit Status Code
O
ID
1/1
NOT USED
INS06
1218
Medicare Plan Code
O
ID
1/1
NOT USED
INS07
1219
Consolidated Omnibus Budget Reconciliation
Act (COBRA) Qualifying
O
ID
1/2
NOT USED
INS08
584
Employment Status Code
O
ID
2/2
NOT USED
INS09
1220
Student Status Code
O
ID
1/1
NOT USED
INS10
1073
Yes/No Condition or Response Code
O
ID
1/1
NOT USED
INS11
1250
Date Time Period Format Qualifier
X
ID
2/3
NOT USED
INS12
1251
Date Time Period
X
AN
1/35
NOT USED
INS13
1165
Confidentiality Code
O
ID
1/1
NOT USED
INS14
19
City Name
O
AN
2/30
NOT USED
INS15
156
State or Province Code
O
ID
2/2
NOT USED
INS16
26
Country Code
O
ID
2/3
SITUATIONAL
INS17
1470
Number
O
N0
1/9
A generic number
INDUSTRY: Birth
Sequence Number
INS17 is the number assigned to each family member born with the
same birth date. This number identifies birth sequence for multiple births allowing
proper tracking and response of benefits for each dependent (i.e., twins, triplets,
etc.).
SEMANTIC:
1301
This data element is not used unless the dependent is a child from
a multiple birth.
180 Original Page Number 299 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
INDIVIDUAL OR ORGANIZATIONAL NAME
NM1
New Loop Added
004010X094A1 • 278 • 2010DB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
004010X094A1
ADDITIONAL PATIENT
INFORMATION
• 278 • 2010DB
• NM1 CONTACT NAME
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT NAME
Loop: 2010DB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
012
100
6
1. Use this NM1 loop to identify the destination location to route the
response for the requested additional patient information.
2. Use this NM1 loop only if
a. the response contains a request for additional patient information
in loop 2000D
015
100
8
b. the destination for the response to the request for additional patient
information differs from the information specified in the UMO Name
NM1 loop (Loop 2010A)
c. the request for additional patient information is not transmitted in
another X12 functional group
3. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.
012
100
9
Refer to Section 2.2.5 for more information on this NM1 loop.
Example: NM1✽2B✽2✽ACME THIRD PARTY ADMINISTRATOR~
012
100
5
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
OCTOBER 2002
New Page inserted after page 299 dated May 2000
181
New
004010X094A1 • 278 • 2010DB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
Segment Added ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DIAGRAM
NM101
NM1 ✽
98
Entity ID
Code
M
ID
NM107
O
✽
2/3
ID
ID
✽
66
NM109
NM104
X
O
67
ID
Code
X
ID
O
706
2/2
1037
Name
Middle
✽
Entity
Relat Code
✽
NM105
AN 1/25
NM110
AN 2/80
1036
Name
First
✽
AN 1/35
✽
1/2
1035
Name Last/
Org Name
O
ID Code
Qualifier
X
NM103
1/1
NM108
✽
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
NM102
ID
O
AN 1/10
98
Entity ID
Code
O
1038
Name
Prefix
✽
AN 1/25
NM111
✽
NM106
~
2/3
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
1P
Provider
2B
Third-Party Administrator
ABG
Organization
Use when the destination is an entity other than
those listed.
1000130
REQUIRED
DEFINITION
NM102
1065
FA
Facility
PR
Payer
X3
Utilization Management Organization
Entity Type Qualifier
M
ID
1/1
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
Person
Use this name only if the destination is an
individual, such as an individual primary care
physician.
1000131
2
182
DEFINITION
Non-Person Entity
New Page inserted after page 299 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
NM103
1035
004010X094A1 • 278 • 2010DB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
New Segment Added
Name Last or Organization Name
O
AN
1/35
Individual last name or organizational name
INDUSTRY: Response
Required if the responder needs to identify the destination by name.
1000132
SITUATIONAL
Contact Last or Organization Name
NM104
1036
Name First
O
AN
1/25
Individual first name
INDUSTRY: Response
Use if NM103 is valued and the destination is an individual (NM102
= 1), such as a primary care provider.
1000133
SITUATIONAL
Contact First Name
NM105
1037
Name Middle
O
AN
1/25
Individual middle name or initial
INDUSTRY: Response
Contact Middle Name
Use if NM104 is present and the middle name/initial of the person is
known.
1233
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Response
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1234
SITUATIONAL
Contact Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
1000134
P0809
Required if the responder needs to use an identifier to identify the
destination.
CODE
24
Employer’s Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification
Use until the National PlanID is mandated if the
destination is a payer.
1000135
XV
1000136
DEFINITION
Health Care Financing Administration National
PlanID
Required if the National PlanID is mandated for use.
Otherwise, one of the other listed codes may be
used.
Use if the destination is a payer.
CODE SOURCE 540: Health Care Financing Administration
National PlanID
OCTOBER 2002
New Page inserted after page 299 dated May 2000
183
New Segment
004010X094A1 • 278 • 2010DB • NM1
ADDITIONAL PATIENT INFORMATION CONTACT NAME
XX
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Use if the destination is a provider.
1000137
SITUATIONAL
Added
NM109
67
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Response
SYNTAX:
Contact Identifier
P0809
Required if NM108 is used.
1000138
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
184 New Page inserted after page 299 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ADDRESS INFORMATION
N3
004010X094A1 • 278 • 2010DB • N3
ADDITIONAL PATIENT INFORMATION CONTACT ADDRESS
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2010DB
• N3 CONTACT ADDRESS
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT ADDRESS
Loop: 2010DB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
014
100
1
1. This segment identifies the office location to route the response to the
request for additional patient information.
015
100
9
2. Use this segment only if the response to the request for additional
patient information must be routed to a specific office location.
014
100
3
3. Do not use if the request for additional patient information is in
another X12 functional group.
Example: N3✽43 SUNRISE BLVD✽SUITE 1000~
014
100
0
STANDARD
N3 Address Information
Level: Detail
Position: 200
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the location of the named party
DIAGRAM
N301
N3 ✽
166
Address
Information
M
AN 1/55
N302
✽
166
Address
Information
O
~
AN 1/55
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
N301
DATA
ELEMENT
166
NAME
ATTRIBUTES
Address Information
M
AN
1/55
Address information
INDUSTRY: Response
Use this element for the first line of the requester’s address.
1000144
SITUATIONAL
Contact Address Line
N302
166
Address Information
O
AN
1/55
Address information
INDUSTRY: Response
1453
OCTOBER 2002
Contact Address Line
Required only if a second address line exists.
New Page inserted after page 299 dated May 2000
185
New Segment Added
004010X094A1 • 278 • 2010DB • N4
ADDITIONAL PATIENT INFORMATION CONTACT CITY/STATE/ZIP CODE
GEOGRAPHIC LOCATION
N4
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL
PATIENT
INFORMATION
• 278 • 2010DB
• N4 CONTACT CITY/STATE/ZIP CODE
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT CITY/STATE/ZIP CODE
Loop: 2010DB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
014
100
1
1. This segment identifies the office location to route the response to the
request for additional patient information.
014
100
2
2. Use this segment only if the subscriber is the patient and the
response to the request for additional patient information must be
routed to a specific office location.
014
100
3
3. Do not use if the request for additional patient information is in
another X12 functional group.
Example: N4✽MIAMI✽FL✽33131✽✽DP✽UTILIZATION REVIEW DEPT~
014
100
6
STANDARD
N4 Geographic Location
Level: Detail
Position: 210
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax:
1. C0605
If N406 is present, then N405 is required.
DIAGRAM
N401
N4 ✽
19
City
Name
O
N402
✽
AN 2/30
156
State or
Prov Code
O
ID
N403
✽
2/2
116
N404
Postal
Code
O
ID
✽
3/15
26
Country
Code
O
ID
N405
✽
2/3
309
Location
Qualifier
X
ID
N406
✽
1/2
310
Location
Identifier
O
~
AN 1/30
ELEMENT SUMMARY
USAGE
SITUATIONAL
REF.
DES.
N401
DATA
ELEMENT
19
NAME
ATTRIBUTES
City Name
O
AN
2/30
Free-form text for city name
INDUSTRY: Response
Contact City Name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.
1000147
186
Use when necessary to provide this data as part of the response
contact location identification.
New Page inserted after page 299 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
N402
156
004010X094A1 • 278 • 2010DB • N4
ADDITIONAL PATIENT INFORMATION CONTACT CITY/STATE/ZIP CODE
State or Province Code
O
ID
2/2
Code (Standard State/Province) as defined by appropriate government agency
INDUSTRY: Response
COMMENT:
N402 is required only if city name (N401) is in the U.S. or Canada.
CODE SOURCE 22:
States and Outlying Areas of the U.S.
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact State or Province Code
N403
116
Postal Code
O
ID
3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
INDUSTRY: Response
CODE SOURCE 51:
ZIP Code
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact Postal Zone or ZIP Code
N404
26
Country Code
O
ID
2/3
X
ID
1/2
O
AN
1/30
Code identifying the country
INDUSTRY: Response
CODE SOURCE 5:
Countries, Currencies and Funds
Use only if the address is out of the U.S.
1317
SITUATIONAL
Contact Country Code
N405
309
Location Qualifier
Code identifying type of location
SYNTAX:
C0605
Required if N406 is valued.
1000148
CODE
SITUATIONAL
N406
310
DEFINITION
B1
Branch
DP
Department
Location Identifier
Code which identifies a specific location
INDUSTRY: Response
SYNTAX:
Contact Specific Information
C0605
1000149
Required if N405 is valued.
1000150
Value this field if the response to the request for additional
information must be directed to a particular domain.
OCTOBER 2002
New Page inserted after page 299 dated May 2000
187
New Segment
004010X094A1 • 278 • 2010DB • PER
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
ADMINISTRATIVE COMMUNICATIONS CONTACT
PER
Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ADDITIONAL
004010X094A1
PATIENT
INFORMATION
• 278 • 2010DB
• PER CONTACT INFORMATION
IMPLEMENTATION
ADDITIONAL PATIENT INFORMATION
CONTACT INFORMATION
Loop: 2010DB — ADDITIONAL PATIENT INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
015
100
3
1. Required if the provider must direct the response to the request for
additional patient information to a specific requester contact,
electronic mail, facsimile, or phone number other than the contact
provided in the PER segment in the UMO Name loop (Loop 2010A)
PER segment of this 278 response.
014
100
3
2. Do not use if the request for additional patient information is in
another X12 functional group.
4
143
3. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.
5
143
4. By definition of the standard, if PER03 is used, PER04 is required.
Example: PER✽IC✽MARY✽FX✽3135554321~
015
100
2
STANDARD
PER Administrative Communications Contact
Level: Detail
Position: 220
Loop: HL/NM1
Requirement: Optional
Max Use: 3
Purpose: To identify a person or office to whom administrative communications should be
directed
Syntax:
1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
188
New Page inserted after page 299 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2010DB • PER
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
DIAGRAM
PER01
PER ✽
366
Contact
Funct Code
M
ID
PER07
PER02
✽
2/2
O
365
PER08
Comm
✽
✽
Number Qual
X
ID
2/2
93
Name
PER03
AN 1/60
X
364
Comm
Number
X
365
PER04
Comm
✽
✽
Number Qual
ID
PER09
2/2
✽
O
X
AN 1/80
PER05
365
PER06
Comm
✽
✽
Number Qual
X
ID
2/2
364
Comm
Number
X
AN 1/80
443
Contact Inq
Reference
AN 1/80
364
Comm
Number
~
AN 1/20
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PER01
DATA
ELEMENT
366
NAME
ATTRIBUTES
Contact Function Code
M
ID
2/2
Code identifying the major duty or responsibility of the person or group named
CODE
IC
SITUATIONAL
PER02
93
DEFINITION
Information Contact
Name
O
AN
1/60
Free-form name
INDUSTRY: Response
Contact Name
1000156
Used only when response must be directed to a particular contact.
1433
Use this data element when the name of the individual to contact is
not already defined or is different than the name within the prior
name segment (e.g. N1 or NM1).
SITUATIONAL
PER03
365
Communication Number Qualifier
X
ID
2/2
Code identifying the type of communication number
SYNTAX:
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
1473
CODE
SITUATIONAL
PER04
364
DEFINITION
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Communication Number
X
AN
1/80
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
1473
OCTOBER 2002
Contact Communication Number
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
New Page inserted after page 299 dated May 2000
189
004010X094A1 • 278 • 2010DB • PER
New Segment Added
ADDITIONAL PATIENT INFORMATION CONTACT INFORMATION
SITUATIONAL
PER05
365
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER06
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
Contact Communication Number
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
SITUATIONAL
PER07
365
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER08
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
NOT USED
190
Contact Communication Number
PER09
443
Contact Inquiry Reference
New Page inserted after page 299 dated May 2000
O
AN
1/20
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HEALTH CARE SERVICES REVIEW
HCR
004010X094A1 • 278 • 2000F • HCR
HEALTH CARE SERVICES REVIEW
004010X094A1
HEALTH CARE•SERVICES
278 • 2000F
REVIEW
• HCR
IMPLEMENTATION
HEALTH CARE SERVICES REVIEW
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:
9
100
1. Use this segment to provide review outcome information and an
associated reference number.
5
134
2. Required if the UMO has reviewed the request. If the UMO was unable
to review the request due to missing or invalid application data at this
level, the UMO must return a 278 response containing a AAA segment
at this level.
2
133
3. If Loop 2000F is present, either the AAA segment or the HCR segment
must be returned.
New
016
100Note 4. Added
0
4. If the review outcome is pending additional medical information and
the 278 response includes a request for additional information using
either a PWK segment or an HI segment that specifies LOINC values,
then the associated HCR segment must be valued with HCR01 = A4
(pended) and HCR03 = 90 (Requested Information Not Received)
Refer to Section 2.2.5 for more information.
Example: HCR✽A1✽19950713~
5
104
STANDARD
HCR Health Care Services Review
Level: Detail
Position: 050
Loop: HL
Requirement: Optional
Max Use: 1
Purpose: To specify the outcome of a health care services review
DIAGRAM
HCR01
HCR
M
OCTOBER 2002
306
Action
Code
✽
ID
HCR02
✽
1/2
127
Reference
Ident
O
AN 1/30
HCR03
✽
901
HCR04
1073
Reject
✽ Yes/No Cond ~
Reason Code
Resp Code
O
ID
2/2
O
ID
1/1
Original Page Number 331 Dated May 2000
191
004010X094A1 • 278 • 2000F • HCR
HEALTH CARE SERVICES REVIEW
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
HCR01
DATA
ELEMENT
306
NAME
ATTRIBUTES
Action Code
M
ID
1/2
AN
1/30
Code indicating type of action
ALIAS: Certification
CODE
A1
Certified in total
A3
Not Certified
A4
Pended
A6
Modified
CT
Contact Payer
NA
No Action Required
Use only if certification is not required.
1346
SITUATIONAL
Action Code
DEFINITION
HCR02
127
Reference Identification
O
Reference information as defined for a particular Transaction Set or as specified
by the Reference Identification Qualifier
INDUSTRY: Certification
SEMANTIC:
Number
HCR02 is the number assigned by the information source to this review
outcome.
Required if HCR01 = A1 or A6.
1347
SITUATIONAL
HCR03
901
Reject Reason Code
O
ID
2/2
Code assigned by issuer to identify reason for rejection
1348
Required if HCR01 = A3 or A4. Use to indicate the primary reason
for the code assigned in HCR01.
CODE
35
Out of Network
36
Testing not Included
37
Request Forwarded To and Decision Response
Forthcoming From an External Review Organization
41
Authorization/Access Restrictions
Use to indicate that the service requested requires
PCP authorization.
1349
192
DEFINITION
53
Inquired Benefit Inconsistent with Provider Type
69
Inconsistent with Patient’s Age
70
Inconsistent with Patient’s Gender
82
Not Medically Necessary
83
Level of Care Not Appropriate
84
Certification Not Required for this Service
Original Page Numbers 331 and 332 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HCR
HEALTH CARE SERVICES REVIEW
85
Certification Responsibility of External Review
Organization
86
Primary Care Service
87
Exceeds Plan Maximums
88
Non-covered Service
Use for services not covered by the patient’s plan
such as Worker’s Compensation or Auto Accident.
1409
89
No Prior Approval
90
Requested Information Not Received
New Note Added
1000161
Use with HCR01 = A4 to indicate that the review
outcome is pending additional medical necessity
information.
91
Duplicate Request
92
Service Inconsistent with Diagnosis
96
Pre-existing Condition
98
Experimental Service or Procedure
E8
Requires Medical Review
Use to indicate that a review by medical personnel is
necessary.
1350
SITUATIONAL
HCR04
1073
Yes/No Condition or Response Code
O
ID
1/1
Code indicating a Yes or No condition or response
INDUSTRY: Second
Surgical Opinion Indicator
HCR04 is the second surgical opinion indicator. A “Y” value indicates a
second surgical opinion is required; an “N” value indicates a second surgical
opinion is not required for this request.
SEMANTIC:
1481
Use when certification pertains to a surgical procedure and the
contract under which the patient is covered has provisions
regarding a second surgical opinion.
CODE
OCTOBER 2002
DEFINITION
N
No
Y
Yes
Original Page Number 332 Dated May 2000
193
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
PROCEDURES• 278 • 2000F • HI
IMPLEMENTATION
PROCEDURES
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 1
Notes:
6
135
1. Use this segment for specific services and procedures.
009
100
4
2. Required if the UMO authorizes specific procedure codes.
New Note 3. Added
010
100
5
3. The UMO can use each occurrence of the Health Care Code
Information composite (C022) to specify codes that identify the
specific information that the UMO requires from the provider to
complete the medical review. In the C022 composite, data elements
1270 and 1271 support the use of codes supplied from the Logical
Observation Identifier Names and Codes (LOINC®) List. These codes
identify high-level health care information groupings, specific data
elements, and associated modifiers.
The Logical Observation Identifier Names and Codes (LOINC®) code
set was intended to increase the functionality of the 278 transaction
set and it is not mandated by HIPAA and is only used when mutually
agreed to by trading partners.
4. If this segment is used to request additional information associated
with a specific procedure, place the specific procedure code in the HI
C022 composite that precedes the HI C022 composite(s) containing
the LOINC. If the original request contained more than six procedure
codes and you are using LOINC to request additional information for
each of these procedure codes or if you need to specify multiple
questions/LOINC codes per procedure you cannot exceed the limit of
12 occurrences of the C022 composite in this HI segment. If
necessary, use additional occurrences of Loop 2000F.
New
009
100 Note Added
4
Refer to Section 2.2.5 of this guide for more information on requesting
additional information.
Example: HI✽BO:490000:D8:19980121::1~
4
148
STANDARD
HI Health Care Information Codes
Level: Detail
Position: 080
Loop: HL
Requirement: Optional
Max Use: 1
Purpose: To supply information related to the delivery of health care
194
Original Page Number 346 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
DIAGRAM
HI01
HI ✽
C022
Health Care
Code Info.
HI02
✽
M
HI03
✽
O
HI07
✽
C022
Health Care
Code Info.
C022
Health Care
Code Info.
✽
HI04
✽
O
HI08
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
✽
HI05
✽
O
HI09
O
C022
Health Care
Code Info.
C022
Health Care
Code Info.
O
HI10
✽
C022
Health Care
Code Info.
HI06
✽
O
C022
Health Care
Code Info.
HI11
✽
O
C022
Health Care
Code Info.
O
C022
Health Care
Code Info.
HI12
✽
O
C022
Health Care
Code Info.
~
O
ELEMENT SUMMARY
REF.
DES.
USAGE
REQUIRED
HI01
DATA
ELEMENT
C022
NAME
ATTRIBUTES
HEALTH CARE CODE INFORMATION
M
To send health care codes and their associated dates, amounts and quantities
ALIAS: Procedure
1144
REQUIRED
HI01 - 1
1270
Code 1
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
New Code Added
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
1000106
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
OCTOBER 2002
Original Page Numbers 346 and 347 Dated May 2000
195
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
New Note Added
REQUIRED
HI01 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
Procedure Code identifying the service.
1215
SITUATIONAL
Code
HI01 - 3
1250
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI01 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
Date
HI01 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI01 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI01-2 for the
same time period.
1358
SITUATIONAL
Quantity
HI01 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
1359
Release, or Industry Identifier
Required if the code list referenced in HI01-1 has a version
identifier. Otherwise Not Used.
196 Original Page Number 347 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI02
C022
004010X094A1 • 278 • 2000F • HI
PROCEDURES
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1147
ALIAS: Procedure
1393
Use this for the second procedure.
REQUIRED
HI02 - 1
1270
Code 2
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
OCTOBER 2002
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Number 347 and 348 Dated May 2000
197
004010X094A1 • 278 • 2000F • HI
PROCEDURES
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI02 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI02 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI02 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
HI02 - 5
782
Monetary Amount
O
R
1/18
Monetary amount
1000163
SITUATIONAL
Usage Changed
Industry Name Added
Note Added
HI02 - 6
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI02-2 for the
same time period.
1410
SITUATIONAL
HI02 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI02-1 has a version
identifier. Otherwise Not Used.
1431
SITUATIONAL
HI03
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1148
ALIAS: Procedure
1394
Use this for the third procedure.
REQUIRED
HI03 - 1
1270
Code 3
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
New Code Added
1000162
198
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Numbers 348 and 349 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
New Code Added
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
REQUIRED
National Drug Code
National Drug Code by Format
HI03 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI03 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
OCTOBER 2002
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
Original Page Number 349 Dated May 2000
199
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI03 - 4
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
HI03 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI03 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI03-2 for the
same time period.
1411
SITUATIONAL
HI03 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI03-1 has a version
identifier. Otherwise Not Used.
1430
SITUATIONAL
HI04
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1149
ALIAS: Procedure
1395
Use this for the fourth procedure.
REQUIRED
HI04 - 1
1270
Code 4
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
200
Original Page Numbers 349 and 350 Dated May 2000
American Dental Association Codes
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Code Added
004010X094A1 • 278 • 2000F • HI
PROCEDURES
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
New Note Added
REQUIRED
National Drug Code
National Drug Code by Format
HI04 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI04 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI04 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
Date
HI04 - 5
782
Monetary Amount
O
R
1/18
Monetary amount
1000163
OCTOBER 2002
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
Original Page Number 350 and 351 Dated May 2000
201
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI04 - 6
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI04-2 for the
same time period.
1412
SITUATIONAL
HI04 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI04-1 has a version
identifier. Otherwise Not Used.
1429
SITUATIONAL
HI05
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1150
ALIAS: Procedure
1396
Use this for the fifth procedure.
REQUIRED
HI05 - 1
1270
Code 5
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
New Code Added
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
202
Original Page Number 351 Dated May 2000
National Drug Code
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
CODE SOURCE 240:
ZZ
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
New Note Added
REQUIRED
HI05 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI05 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI05 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
HI05 - 5
782
INDUSTRY: Procedure
HI05 - 6
O
R
1/18
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
1000163
SITUATIONAL
Monetary Amount
Monetary amount
Usage Changed
Industry Name Added
Note Added
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI05-2 for the
same time period.
1413
SITUATIONAL
Quantity
HI05 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
1428
OCTOBER 2002
Release, or Industry Identifier
Required if the code list referenced in HI05-1 has a version
identifier. Otherwise Not Used.
Original Page Number 352 Dated May 2000
203
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
HI06
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1151
ALIAS: Procedure
1397
Use this for the sixth procedure.
REQUIRED
HI06 - 1
1270
Code 6
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
New Code Added
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
204
National Drug Code
National Drug Code by Format
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Numbers 352 and 353 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
HI06 - 2
004010X094A1 • 278 • 2000F • HI
PROCEDURES
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI06 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI06 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
HI06 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI06 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI06-2 for the
same time period.
1414
SITUATIONAL
HI06 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Release, or Industry Identifier
Required if the code list referenced in HI06-1 has a version
identifier. Otherwise Not Used.
1427
SITUATIONAL
HI07
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1152
ALIAS: Procedure
1398
Use this for the seventh procedure.
REQUIRED
HI07 - 1
1270
Code 7
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
1000162
OCTOBER 2002
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
Original Page Number 353 and 354 Dated May 2000
205
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
New Code Added
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
New Note Added
REQUIRED
HI07 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI07 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
206
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
Original Page Number 354 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI07 - 4
004010X094A1 • 278 • 2000F • HI
PROCEDURES
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
Date
HI07 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI07 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI07-2 for the
same time period.
1415
SITUATIONAL
Quantity
HI07 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI07-1 has a version
identifier. Otherwise Not Used.
1426
SITUATIONAL
Release, or Industry Identifier
HI08
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1153
ALIAS: Procedure
1399
Use this for the eighth procedure.
REQUIRED
HI08 - 1
1270
Code 8
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
OCTOBER 2002
American Dental Association Codes
Original Page Number 354 and 355 Dated May 2000
207
004010X094A1 • 278 • 2000F • HI
PROCEDURES
New Code Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
REQUIRED
HI08 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI08 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI08 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
HI08 - 5
782
Monetary Amount
O
R
1/18
Monetary amount
1000163
208
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
Original Page Numbers 355 and 356 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI08 - 6
004010X094A1 • 278 • 2000F • HI
PROCEDURES
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI08-2 for the
same time period.
1416
SITUATIONAL
Quantity
HI08 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI08-1 has a version
identifier. Otherwise Not Used.
1425
SITUATIONAL
Release, or Industry Identifier
HI09
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1154
ALIAS: Procedure
1400
Use this for the ninth procedure.
REQUIRED
HI09 - 1
1270
Code 9
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
New Code Added
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
OCTOBER 2002
National Drug Code
Original Page Number 356 Dated May 2000
209
004010X094A1 • 278 • 2000F • HI
PROCEDURES
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
CODE SOURCE 240:
ZZ
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
New Note Added
REQUIRED
HI09 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI09 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI09 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Date
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
HI09 - 5
782
INDUSTRY: Procedure
HI09 - 6
O
R
1/18
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
1000163
SITUATIONAL
Monetary Amount
Monetary amount
Usage Changed
Industry Name Added
Note Added
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Quantity
Required if requesting authorization for more than one
occurrence of the procedure identified in HI09-2 for the
same time period.
1417
SITUATIONAL
HI09 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
1424
210
Release, or Industry Identifier
Required if the code list referenced in HI09-1 has a version
identifier. Otherwise Not Used.
Original Page Numbers 356 and 357 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
HI10
C022
004010X094A1 • 278 • 2000F • HI
PROCEDURES
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1155
ALIAS: Procedure
1401
Use this for the tenth procedure.
REQUIRED
HI10 - 1
1270
Code 10
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
New Code Added
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
1392
New Note Added
OCTOBER 2002
National Drug Code
National Drug Code by Format
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
Original Page Number 357 Dated May 2000
211
004010X094A1 • 278 • 2000F • HI
PROCEDURES
REQUIRED
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI10 - 2
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI10 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI10 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
Date
HI10 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI10 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI10-2 for the
same time period.
1418
SITUATIONAL
Quantity
HI10 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI10-1 has a version
identifier. Otherwise Not Used.
1423
SITUATIONAL
Release, or Industry Identifier
HI11
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1156
ALIAS: Procedure
1402
Use this for the eleventh procedure.
REQUIRED
HI11 - 1
1270
Code 11
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
1000162
212 Original Page Number 358 Dated May 2000
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1 • 278 • 2000F • HI
PROCEDURES
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
New Code Added
LOI
American Dental Association Codes
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
REQUIRED
National Drug Code
National Drug Code by Format
HI11 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI11 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
OCTOBER 2002
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
Original Page Number 359 Dated May 2000
213
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
HI11 - 4
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
1000163
SITUATIONAL
Date
HI11 - 5
782
O
R
1/18
Monetary amount
Usage Changed
Industry Name Added
Note Added
HI11 - 6
Monetary Amount
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI11-2 for the
same time period.
1419
SITUATIONAL
Quantity
HI11 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
Required if the code list referenced in HI11-1 has a version
identifier. Otherwise Not Used.
1422
SITUATIONAL
Release, or Industry Identifier
HI12
C022
HEALTH CARE CODE INFORMATION
O
To send health care codes and their associated dates, amounts and quantities
1157
ALIAS: Procedure
1403
Use this for the twelfth procedure.
REQUIRED
HI12 - 1
1270
Code 12
Code List Qualifier Code
M
ID
1/3
Code identifying a specific industry code list
CODE
New Code Added
ABR
DEFINITION
Assigned by Receiver
Use ABR for Revenue Codes in Code Source 132:
National Uniform Billing Committee (NUBC) codes.
1000162
BO
Health Care Financing Administration Common
Procedural Coding System
Because the AMA’s CPT codes are also level 1
HCPCS codes, they are reported under BO.
1391
CODE SOURCE 130: Health Care Financing Administration
Common Procedural Coding System
BQ
International Classification of Diseases Clinical
Modification (ICD-9-CM) Procedure
CODE SOURCE 131: International Classification of Diseases
Clinical Mod (ICD-9-CM) Procedure
JP
National Standard Tooth Numbering System
CODE SOURCE 135:
214 Original Page Numbers 359 and 360 Dated May 2000
American Dental Association Codes
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Code Added
004010X094A1 • 278 • 2000F • HI
PROCEDURES
LOI
Logical Observation Identifier Names and Codes
(LOINC) Codes
The Logical Observation Identifier Names and
Codes (LOINC®) code set was intended to increase
the functionality of the 278 transaction set and it is
not mandated by HIPAA and is only used when
mutually agreed to by trading partners.
1000106
See Section 2.2.5 for information on using LOINC to
request additional information.
CODE SOURCE 663: Logical Observation Identifier Names and
Codes (LOINC)
NDC
National Drug Code (NDC)
CODE SOURCE 134:
CODE SOURCE 240:
ZZ
Mutually Defined
Use ZZ for Code Source 513: Home Infusion EDI
Coalition (HIEC) Product / Service Code List.
1392
New Note Added
REQUIRED
National Drug Code
National Drug Code by Format
HI12 - 2
This code set is not allowed for use under HIPAA at
the time of this writing. The qualifier can only be
used 1) If a new rule names HIEC as an allowable
code set under HIPAA. 2) For Property & Casualty
claims/encounters that are not covered under
HIPAA.
1271
Industry Code
M
AN
1/30
ID
2/3
Code indicating a code from a specific industry code list
INDUSTRY: Procedure
SITUATIONAL
HI12 - 3
1250
Code
Date Time Period Format Qualifier
X
Code indicating the date format, time format, or date and time format
Required if X12N syntax conditions apply.
1224
CODE
SITUATIONAL
HI12 - 4
DEFINITION
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDDCCYYMMDD
1251
Date Time Period
X
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY: Procedure
Required if proposed or actual procedure date is known.
1357
SITUATIONAL
Date
HI12 - 5
782
Monetary Amount
O
R
1/18
Monetary amount
1000163
OCTOBER 2002
Usage Changed
Industry Name Added
Note Added
INDUSTRY: Procedure
Monetary Amount
Use if the UMO has approved the health care service with
monetary limitations.
Original Page Number 360 Dated May 2000
215
004010X094A1 • 278 • 2000F • HI
PROCEDURES
SITUATIONAL
HI12 - 6
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
380
Quantity
O
R
1/15
Numeric value of quantity
INDUSTRY: Procedure
Required if requesting authorization for more than one
occurrence of the procedure identified in HI12-2 for the
same time period.
1420
SITUATIONAL
Quantity
HI12 - 7
799
Version Identifier
O
AN
1/30
Revision level of a particular format, program, technique or algorithm
INDUSTRY: Version,
1421
Release, or Industry Identifier
Required if the code list referenced in HI12-1 has a version
identifier. Otherwise Not Used.
216 Original Page Numbers 360 and 361 Dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
PAPERWORK
PWK
New Segment Added
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
004010X094A1
ADDITIONAL SERVICE
INFORMATION
• 278 • 2000F
• PWK
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
Loop: 2000F — SERVICE LEVEL
Usage: SITUATIONAL
Repeat: 10
Notes:
016
100
5
1. The UMO can use this PWK segment on the response to request
additional information that applies to the service(s) requested in this
Service loop. If the UMO has pended the decision on this health care
services review request (HCR01 = A4) because additional medical
necessity information is required (HCR03 = 90), the UMO can use this
segment to identify the type of documentation needed such as forms
that the provider must complete. The UMO can also indicate what
medium it has used to send these forms.
016
100
6
2. Additional information requested at the Service level should apply to a
specific service and/or all the services requested in this service loop.
011
100
0
3. This PWK segment is required to identify requests for specific data
that are sent electronically (PWK02 = EL) but are transmitted in
another X12 functional group rather than by paper or using LOINC in
the HI segments of the response. PWK06 is used to identify the
attached electronic questionnaire. The number in PWK06 should be
referenced in the corresponding electronic attachment.
011
100
1
4. This PWK segment should not be used if
a. the requester should have provided the information within the 278
request (ST-SE) but failed to do so. In this case the UMO should use
the AAA segments in the 278 response to indicate the data that is
missing or invalid.
b. the 278 request (ST-SE) does not support this information and the
needed information pertains to all the services requested and not to a
specific service. Use the PWK segment at the Patient level (Loop
2000C or Loop 2000D) if requesting medical necessity information that
applies to all the services requested
Refer to Section 2.2.5 for more information on using this segment.
Example: PWK✽OB✽BM✽✽✽AC✽DMN0012~
011
100
2
STANDARD
PWK Paperwork
Level: Detail
Position: 155
Loop: HL
Requirement: Optional
Max Use: >1
OCTOBER 2002
New Page inserted after page 382 dated May 2000
217
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
Purpose: To identify the type or transmission or both of paperwork or supporting
information
Syntax:
1. P0506
If either PWK05 or PWK06 is present, then the other is required.
DIAGRAM
PWK01
PWK
755
PWK02
✽ Report Type ✽
Code
M
ID
PWK07
✽
2/2
O
352
PWK08
Description
O
AN 1/80
756
PWK03
757
PWK04
Report
Report
✽
✽
Copies Need
Transm Code
ID
1/2
C002
Actions
Indicated
✽
O
N0
PWK09
✽
O
1/2
ID
O
ID
PWK05
2/3
66
ID Code
Qualifier
✽
X
ID
PWK06
1/2
67
ID
Code
✽
X
AN 2/80
1525
Request
Categ Code
O
98
Entity ID
Code
~
1/2
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PWK01
DATA
ELEMENT
755
NAME
ATTRIBUTES
Report Type Code
M
ID
2/2
Code indicating the title or contents of a document, report or supporting item
INDUSTRY: Attachment
CODE
Report Type Code
DEFINITION
03
Report Justifying Treatment Beyond Utilization
Guidelines
04
Drugs Administered
05
Treatment Diagnosis
06
Initial Assessment
07
Functional Goals
Expected outcomes of rehabilitative services.
1000113
08
Plan of Treatment
09
Progress Report
10
Continued Treatment
11
Chemical Analysis
13
Certified Test Report
15
Justification for Admission
21
Recovery Plan
48
Social Security Benefit Letter
55
Rental Agreement
Use for medical or dental equipment rental.
1000114
59
Benefit Letter
218 New Page inserted after page 382 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
77
Support Data for Verification
A3
Allergies/Sensitivities Document
A4
Autopsy Report
AM
Ambulance Certification
Information to support necessity of ambulance trip.
1000115
AS
Admission Summary
A brief patient summary; it lists the patient’s chief
complaints and the reasons for admitting the patient
to the hospital.
1000116
AT
Purchase Order Attachment
Use for purchase of medical or dental equipment.
1000117
B2
Prescription
B3
Physician Order
BR
Benchmark Testing Results
BS
Baseline
BT
Blanket Test Results
CB
Chiropractic Justification
Lists the reasons chiropractic is just and
appropriate treatment.
1000118
OCTOBER 2002
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
CK
Consent Form(s)
D2
Drug Profile Document
DA
Dental Models
DB
Durable Medical Equipment Prescription
DG
Diagnostic Report
DJ
Discharge Monitoring Report
DS
Discharge Summary
FM
Family Medical History Document
HC
Health Certificate
HR
Health Clinic Records
I5
Immunization Record
IR
State School Immunization Records
LA
Laboratory Results
M1
Medical Record Attachment
NN
Nursing Notes
New Page inserted after page 382 dated May 2000
219
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
REQUIRED
PWK02
756
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
OB
Operative Note
OC
Oxygen Content Averaging Report
OD
Orders and Treatments Document
OE
Objective Physical Examination (including vital
signs) Document
OX
Oxygen Therapy Certification
P4
Pathology Report
P5
Patient Medical History Document
P6
Periodontal Charts
P7
Periodontal Reports
PE
Parenteral or Enteral Certification
PN
Physical Therapy Notes
PO
Prosthetics or Orthotic Certification
PQ
Paramedical Results
PY
Physician’s Report
PZ
Physical Therapy Certification
QC
Cause and Corrective Action Report
QR
Quality Report
RB
Radiology Films
RR
Radiology Reports
RT
Report of Tests and Analysis Report
RX
Renewable Oxygen Content Averaging Report
SG
Symptoms Document
V5
Death Notification
XP
Photographs
Report Transmission Code
O
ID
1/2
Code defining timing, transmission method or format by which reports are to be
sent
INDUSTRY: Attachment
CODE
1000119
220
Transmission Code
DEFINITION
BM
By Mail
EL
Electronically Only
Use to indicate that attachment is being transmitted
in a separate X12 functional group.
New Page inserted after page 382 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
New Segment Added
EM
E-Mail
FX
By Fax
VO
Voice
004010X094A1 • 278 • 2000F • PWK
ADDITIONAL SERVICE INFORMATION
Use this for voicemail or phone communication.
1000120
NOT USED
PWK03
757
Report Copies Needed
O
N0
1/2
NOT USED
PWK04
98
Entity Identifier Code
O
ID
2/3
SITUATIONAL
PWK05
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
P0506
COMMENT:
PWK05 and PWK06 may be used to identify the addressee by a code
number.
This data element is required when PWK02 DOES NOT equal “VO”.
1000121
CODE
AC
SITUATIONAL
PWK06
67
DEFINITION
Attachment Control Number
Identification Code
X
AN
2/80
O
AN
1/80
Code identifying a party or other code
INDUSTRY: Attachment
SYNTAX:
Required if PWK02 equals BM, EL, EM or FX.
1000122
SITUATIONAL
Control Number
P0506
PWK07
352
Description
A free-form description to clarify the related data elements and their content
INDUSTRY: Attachment
Description
COMMENT: PWK07 may be used to indicate special information to be shown on the
specified report.
This data element is used to add any additional information about
the attachment described in this segment.
1000123
NOT USED
PWK08
C002
ACTIONS INDICATED
O
NOT USED
PWK09
1525
Request Category Code
O
OCTOBER 2002
ID
New Page inserted after page 382 dated May 2000
1/2
221
New Loop
004010X094A1 • 278 • 2010F • NM1
ADDITIONAL SERVICE INFORMATION CONTACT NAME
Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL SERVICE
INFORMATION
• 278 • 2010F
• NM1 CONTACT NAME
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
CONTACT NAME
Loop: 2010F — ADDITIONAL SERVICE INFORMATION CONTACT NAME
Repeat: 1
Usage: SITUATIONAL
Repeat: 1
Notes:
012
100
6
1. Use this NM1 loop to identify the destination location to route the
response for the requested additional information.
2. Use this NM1 loop only if
a. the response contains a request for additional information in this
service loop.
015
100
8
b. the destination for the response to the request for additional
information differs from the information specified in the UMO Name
NM1 loop (Loop 2010A)
c. the request for additional service information is not transmitted in
another X12 functional group
3. Because the usage of this segment is “Situational” this is not a
syntactically required loop. If this loop is used, then this segment is a
“Required” segment. See Appendix A for further details on ASC X12
syntax rules.
012
100
9
Refer to Section 2.2.5 for more information on this NM1 loop.
Example: NM1✽2B✽2✽ACME THIRD PARTY ADMINISTRATOR~
012
100
5
STANDARD
NM1 Individual or Organizational Name
Level: Detail
Position: 170
Loop: HL/NM1 Repeat: >1
Requirement: Optional
Max Use: 1
Purpose: To supply the full name of an individual or organizational entity
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.
222
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ADDITIONAL SERVICE INFORMATION CONTACT NAME
New Segment Added
DIAGRAM
NM101
NM1 ✽
98
Entity ID
Code
M
ID
NM107
O
✽
2/3
ID
ID
✽
66
NM109
NM104
X
O
67
ID
Code
X
ID
O
706
1037
Name
Middle
✽
Entity
Relat Code
✽
NM105
AN 1/25
NM110
AN 2/80
1036
Name
First
✽
AN 1/35
✽
1/2
1035
Name Last/
Org Name
O
ID Code
Qualifier
X
NM103
1/1
NM108
✽
AN 1/10
1065
Entity Type
Qualifier
M
1039
Name
Suffix
✽
NM102
O
ID
O
AN 1/10
98
Entity ID
Code
✽
1038
Name
Prefix
✽
AN 1/25
NM111
2/2
NM106
~
2/3
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
NM101
DATA
ELEMENT
98
NAME
ATTRIBUTES
Entity Identifier Code
M
ID
2/3
Code identifying an organizational entity, a physical location, property or an
individual
CODE
1P
Provider
2B
Third-Party Administrator
ABG
Organization
Use when the destination is an entity other than
those listed.
1000130
REQUIRED
DEFINITION
NM102
1065
FA
Facility
PR
Payer
X3
Utilization Management Organization
Entity Type Qualifier
M
ID
1/1
Code qualifying the type of entity
SEMANTIC:
NM102 qualifies NM103.
CODE
1
Person
Use this name only if the destination is an
individual, such as an individual primary care
physician.
1000131
2
SITUATIONAL
DEFINITION
NM103
1035
Non-Person Entity
Name Last or Organization Name
O
AN
1/35
Individual last name or organizational name
INDUSTRY: Response
1000132
OCTOBER 2002
Contact Last or Organization Name
Required if the responder needs to identify the destination by name.
New Page inserted after page 383 dated May 2000
223
004010X094A1 • 278 • 2010F • NM1
ADDITIONAL SERVICE INFORMATION CONTACT NAME New
SITUATIONAL
NM104
1036
Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Name First
O
AN
1/25
Individual first name
INDUSTRY: Response
Use if NM103 is valued and the destination is an individual (NM102
= 1), such as a primary care provider.
1000133
SITUATIONAL
Contact First Name
NM105
1037
Name Middle
O
AN
1/25
Individual middle name or initial
INDUSTRY: Response
Contact Middle Name
Use if NM104 is present and the middle name/initial of the person is
known.
1233
NOT USED
NM106
1038
Name Prefix
O
AN
1/10
SITUATIONAL
NM107
1039
Name Suffix
O
AN
1/10
Suffix to individual name
INDUSTRY: Response
Use this for the suffix of an individual’s name; e.g., Sr., Jr., or III.
1234
SITUATIONAL
Contact Name Suffix
NM108
66
Identification Code Qualifier
X
ID
1/2
Code designating the system/method of code structure used for Identification
Code (67)
SYNTAX:
1000134
P0809
Required if the responder needs to use an identifier to identify the
destination.
CODE
DEFINITION
24
Employer’s Identification Number
34
Social Security Number
46
Electronic Transmitter Identification Number (ETIN)
PI
Payor Identification
Use until the National PlanID is mandated if the
destination is a payer.
1000135
XV
Health Care Financing Administration National
PlanID
Required if the National PlanID is mandated for use.
Otherwise, one of the other listed codes may be
used.
Use if the destination is a payer.
1000136
CODE SOURCE 540: Health Care Financing Administration
National PlanID
XX
1000137
224
Health Care Financing Administration National
Provider Identifier
Required value if the National Provider ID is
mandated for use. Otherwise, one of the other listed
codes may be used.
Use if the destination is a provider.
New Page inserted after page 383 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
NM109
67
004010X094A1 • 278 • 2010F • NM1
ADDITIONAL SERVICE INFORMATION CONTACT NAME
Identification Code
X
AN
2/80
Code identifying a party or other code
INDUSTRY: Response
SYNTAX:
Contact Identifier
P0809
Required if NM108 is used.
1000138
NOT USED
NM110
706
Entity Relationship Code
X
ID
2/2
NOT USED
NM111
98
Entity Identifier Code
O
ID
2/3
OCTOBER 2002
New Page inserted after page 383 dated May 2000
225
New Segment Added
004010X094A1 • 278 • 2010F • N3
ADDITIONAL SERVICE INFORMATION CONTACT ADDRESS
ADDRESS INFORMATION
N3
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1
ADDITIONAL SERVICE
INFORMATION
CONTACT ADDRESS
• 278 • 2010F
• N3
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
CONTACT ADDRESS
Loop: 2010F — ADDITIONAL SERVICE INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
017
100
2
1. This segment identifies the office location to route the response to the
request for additional service information.
016
100
9
2. Use this segment only if the response to the request for additional
service information must be routed to a specific office location.
017
100
0
3. Do not use if the request for additional service information is in
another X12 functional group.
Example: N3✽43 SUNRISE BLVD✽SUITE 1000~
014
100
0
STANDARD
N3 Address Information
Level: Detail
Position: 200
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the location of the named party
DIAGRAM
N301
N3 ✽
166
Address
Information
M
AN 1/55
N302
✽
166
Address
Information
O
~
AN 1/55
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
N301
DATA
ELEMENT
166
NAME
ATTRIBUTES
Address Information
M
AN
1/55
Address information
INDUSTRY: Response
Use this element for the first line of the requester’s address.
1000144
SITUATIONAL
Contact Address Line
N302
166
Address Information
O
AN
1/55
Address information
INDUSTRY: Response
1453
226
Contact Address Line
Required only if a second address line exists.
New Page inserted after page 383 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
GEOGRAPHIC LOCATION
N4
004010X094A1 • 278 • 2010F • N4
ADDITIONAL SERVICE INFORMATION CONTACT CITY/STATE/ZIP CODE
004010X094A1
ADDITIONAL SERVICE
INFORMATION
CONTACT CITY/STATE/ZIP CODE
• 278 • 2010F
• N4
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
CONTACT CITY/STATE/ZIP CODE
Loop: 2010F — ADDITIONAL SERVICE INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
017
100
2
1. This segment identifies the office location to route the response to the
request for additional service information.
016
100
9
2. Use this segment only if the response to the request for additional
service information must be routed to a specific office location.
017
100
0
3. Do not use if the request for additional service information is in
another X12 functional group.
Example: N4✽MIAMI✽FL✽33131✽✽DP✽UTILIZATION REVIEW DEPT~
014
100
6
STANDARD
N4 Geographic Location
Level: Detail
Position: 210
Loop: HL/NM1
Requirement: Optional
Max Use: 1
Purpose: To specify the geographic place of the named party
Syntax:
1. C0605
If N406 is present, then N405 is required.
DIAGRAM
N401
N4 ✽
19
City
Name
O
N402
✽
AN 2/30
156
State or
Prov Code
O
ID
N403
✽
2/2
116
Postal
Code
O
ID
3/15
N404
26
Country
Code
✽
O
ID
N405
✽
2/3
309
Location
Qualifier
X
ID
N406
✽
1/2
310
Location
Identifier
O
~
AN 1/30
ELEMENT SUMMARY
USAGE
SITUATIONAL
REF.
DES.
N401
DATA
ELEMENT
19
NAME
ATTRIBUTES
City Name
O
AN
2/30
Free-form text for city name
INDUSTRY: Response
Contact City Name
COMMENT: A combination of either N401 through N404, or N405 and N406 may be
adequate to specify a location.
1000147
OCTOBER 2002
Use when necessary to provide this data as part of the response
contact location identification.
New Page inserted after page 383 dated May 2000
227
New Segment Added
004010X094A1 • 278 • 2010F • N4
ADDITIONAL SERVICE INFORMATION CONTACT CITY/STATE/ZIP CODE
SITUATIONAL
N402
156
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
State or Province Code
O
ID
2/2
Code (Standard State/Province) as defined by appropriate government agency
INDUSTRY: Response
COMMENT:
N402 is required only if city name (N401) is in the U.S. or Canada.
CODE SOURCE 22:
States and Outlying Areas of the U.S.
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact State or Province Code
N403
116
Postal Code
O
ID
3/15
Code defining international postal zone code excluding punctuation and blanks
(zip code for United States)
INDUSTRY: Response
CODE SOURCE 51:
ZIP Code
Use when necessary to provide this data as part of the response
contact location identification.
1000147
SITUATIONAL
Contact Postal Zone or ZIP Code
N404
26
Country Code
O
ID
2/3
X
ID
1/2
O
AN
1/30
Code identifying the country
INDUSTRY: Response
CODE SOURCE 5:
Countries, Currencies and Funds
Use only if the address is out of the U.S.
1317
SITUATIONAL
Contact Country Code
N405
309
Location Qualifier
Code identifying type of location
SYNTAX:
C0605
Required if N406 is valued.
1000148
CODE
SITUATIONAL
N406
310
DEFINITION
B1
Branch
DP
Department
Location Identifier
Code which identifies a specific location
INDUSTRY: Response
SYNTAX:
Contact Specific Location
C0605
1000149
Required if N405 is valued.
1000150
Value this field if the response to the request for additional
information must be directed to a particular domain.
228 New Page inserted after page 383 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
ADMINISTRATIVE COMMUNICATIONS CONTACT
PER
New Segment Added
004010X094A1 • 278 • 2010F • PER
ADDITIONAL SERVICE INFORMATION CONTACT INFORMATION
ADDITIONAL
004010X094A1
SERVICE
INFORMATION
• 278 • 2010F
• PER CONTACT INFORMATION
IMPLEMENTATION
ADDITIONAL SERVICE INFORMATION
CONTACT INFORMATION
Loop: 2010F — ADDITIONAL SERVICE INFORMATION CONTACT NAME
Usage: SITUATIONAL
Repeat: 1
Notes:
017
100
4
1. Required if the provider must direct the response to the request for
additional service information to a specific requester contact,
electronic mail, facsimile, or phone number other than the contact
provided in the PER segment in the UMO Name loop (Loop 2010A)
PER segment of this 278 response.
017
100
0
2. Do not use if the request for additional service information is in
another X12 functional group.
4
143
3. When the communication number represents a telephone number in
the United States and other countries using the North American
Dialing Plan (for voice, data, fax, etc), the communication number
should always include the area code and phone number using the
format AAABBBCCCC. Where AAA is the area code, BBB is the
telephone number prefix, and CCCC is the telephone number (e.g.
(534)224-2525 would be represented as 5342242525). The extension,
when applicable, should be included in the communication number
immediately after the telephone number.
5
143
4. By definition of the standard, if PER03 is used, PER04 is required.
Example: PER✽IC✽MARY✽FX✽3135554321~
015
100
2
STANDARD
PER Administrative Communications Contact
Level: Detail
Position: 220
Loop: HL/NM1
Requirement: Optional
Max Use: 3
Purpose: To identify a person or office to whom administrative communications should be
directed
Syntax:
1. P0304
If either PER03 or PER04 is present, then the other is required.
2. P0506
If either PER05 or PER06 is present, then the other is required.
3. P0708
If either PER07 or PER08 is present, then the other is required.
OCTOBER 2002
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229
New Segment Added
004010X094A1 • 278 • 2010F • PER
ADDITIONAL SERVICE INFORMATION CONTACT INFORMATION
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
DIAGRAM
PER01
PER ✽
366
Contact
Funct Code
M
ID
PER07
PER02
✽
2/2
O
365
PER08
Comm
✽
✽
Number Qual
X
ID
2/2
93
Name
PER03
AN 1/60
X
364
Comm
Number
X
365
PER04
Comm
✽
✽
Number Qual
ID
PER09
2/2
✽
O
X
AN 1/80
PER05
365
PER06
Comm
✽
✽
Number Qual
X
ID
2/2
364
Comm
Number
X
AN 1/80
443
Contact Inq
Reference
AN 1/80
364
Comm
Number
~
AN 1/20
ELEMENT SUMMARY
USAGE
REF.
DES.
REQUIRED
PER01
DATA
ELEMENT
366
NAME
ATTRIBUTES
Contact Function Code
M
ID
2/2
Code identifying the major duty or responsibility of the person or group named
CODE
IC
SITUATIONAL
PER02
93
DEFINITION
Information Contact
Name
O
AN
1/60
Free-form name
INDUSTRY: Response
Contact Name
1000156
Used only when response must be directed to a particular contact.
1433
Use this data element when the name of the individual to contact is
not already defined or is different than the name within the prior
name segment (e.g. N1 or NM1).
SITUATIONAL
PER03
365
Communication Number Qualifier
X
ID
2/2
Code identifying the type of communication number
SYNTAX:
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
1473
CODE
SITUATIONAL
PER04
364
DEFINITION
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Communication Number
X
AN
1/80
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
1473
230
Contact Communication Number
P0304
Required if PER02 is not valued and may be used if necessary to
transmit a contact communication number.
New Page inserted after page 383 dated May 2000
OCTOBER 2002
New Segment Added
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
SITUATIONAL
PER05
365
004010X094A1 • 278 • 2010F • PER
ADDITIONAL SERVICE INFORMATION CONTACT INFORMATION
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER06
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
P0506
Used only when the telephone extension or multiple
communication types are available.
1238
SITUATIONAL
Contact Communication Number
PER07
365
Communication Number Qualifier
X
ID
2/2
AN
1/80
Code identifying the type of communication number
SYNTAX:
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
CODE
SITUATIONAL
PER08
364
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Communication Number
X
Complete communications number including country or area code when
applicable
INDUSTRY: Response
SYNTAX:
OCTOBER 2002
P0708
Used only when the telephone extension or multiple
communication types are available.
1238
NOT USED
Contact Communication Number
PER09
443
Contact Inquiry Reference
O
AN
1/20
New Page inserted after page 383 dated May 2000
231
004010X094A1 • 278
HEALTH CARE SERV. REVIEW - REQUEST FOR REVIEW & RESPONSE
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
Data elements are assigned a unique reference number. Each data element has
a name, description, type, minimum length, and maximum length. For ID type
data elements, this guide provides the applicable ASC X12 code values and their
descriptions or references where the valid code list can be obtained.
Each data element is assigned a minimum and maximum length. The length of
the data element value is the number of character positions used except as
noted for numeric, decimal, and binary elements.
The data element types shown in matrix A4, Data Element Types, appear in this
implementation guide.
SYMBOL
TYPE
Nn
Numeric
R
Decimal
ID
Identifier
AN
String
DT
Date
TM
Time
B
Binary
Matrix A4. Data Element Types
A.1.3.1.1
Numeric
A numeric data element is represented by one or more digits with an optional
leading sign representing a value in the normal base of 10. The value of a numeric data element includes an implied decimal point. It is used when the position of the decimal point within the data is permanently fixed and is not to be
transmitted with the data.
This set of guides denotes the number of implied decimal positions. The representation for this data element type is “Nn” where N indicates that it is numeric
and n indicates the number of decimal positions to the right of the implied decimal point.
If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus sign (+) should not be transmitted.
EXAMPLE
A transmitted value of 1234, when specified as numeric type N2, represents a
value of 12.34.
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. The length of a numeric type data element does not include
the optional sign.
A.1.3.1.2
Decimal
A decimal data element may contain an explicit decimal point and is used for numeric values that have a varying number of decimal positions. This data element
type is represented as “R.”
The decimal point always appears in the character stream if the decimal point is
at any place other than the right end. If the value is an integer (decimal point at
the right end) the decimal point should be omitted. For negative values, the leading minus sign (-) is used. Absence of a sign indicates a positive value. The plus
sign (+) should not be transmitted.
232
Original Page Number A.5 dated May 2000
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IMPLEMENTATION GUIDE
004010X094A1 • 278
HEALTH CARE SERV. REVIEW - REQUEST FOR REVIEW & RESPONSE
Leading zeros should be suppressed unless necessary to satisfy a minimum
length requirement. Trailing zeros following the decimal point should be suppressed unless necessary to indicate precision. The use of triad separators (for
example, the commas in 1,000,000) is expressly prohibited. The length of a decimal type data element does not include the optional leading sign or decimal point.
EXAMPLE
A transmitted value of 12.34 represents a decimal value of 12.34.
New note
A.1.3.1.3
For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in
Data Element 782 (Monetary Amount) will be limited to a maximum length of 10
characters including reported or implied places for cents (implied value of 00 after
the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.
Identifier
An identifier data element always contains a value from a predefined list of codes
that is maintained by the ASC X12 Committee or some other body recognized by
the Committee. Trailing spaces should be suppressed unless they are necessary
to satisfy a minimum length. An identifier is always left justified. The representation for this data element type is “ID.”
A.1.3.1.4
String
A string data element is a sequence of any characters from the basic or extended
character sets. The significant characters shall be left justified. Leading spaces,
when they occur, are presumed to be significant characters. Trailing spaces
should be suppressed unless they are necessary to satisfy a minimum length.
The representation for this data element type is “AN.”
A.1.3.1.5
Date
A date data element is used to express the standard date in either YYMMDD or
CCYYMMDD format in which CC is the first two digits of the calendar year, YY is
the last two digits of the calendar year, MM is the month (01 to 12), and DD is the
day in the month (01 to 31). The representation for this data element type is “DT.”
Users of this guide should note that all dates within transactions are 8-character
dates (millennium compliant) in the format CCYYMMDD. The only date data element that is in format YYMMDD is the Interchange Date data element in the ISA
segment, and also used in the TA1 Interchange Acknowledgment, where the century can be readily interpolated because of the nature of an interchange header.
A.1.3.1.6
Time
A time data element is used to express the ISO standard time HHMMSSd..d format in which HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00
to 59), SS is the second (00 to 59) and d..d is decimal seconds. The representation for this data element type is “TM.” The length of the data element determines the format of the transmitted time.
EXAMPLE
Transmitted data elements of four characters denote HHMM. Transmitted data
elements of six characters denote HHMMSS.
OCTOBER 2002
Original Page Number A.6 dated May 2000
233
004010X094A1 • 278 • GS
FUNCTIONAL GROUP HEADER
FUNCTIONAL GROUP HEADER
GS
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
004010X094A1GROUP
FUNCTIONAL
GS
• 002 • HEADER
IMPLEMENTATION
FUNCTIONAL GROUP HEADER
Example: GS✽HI✽SENDER CODE✽RECEIVER
CODE✽19940331✽0802✽1✽X✽004010X094A1~
005
100
4
Example changed
STANDARD
GS Functional Group Header
Purpose: To indicate the beginning of a functional group and to provide control information
DIAGRAM
GS01
GS ✽
479
Functional
ID Code
M
ID
GS07
GS02
2/2
M
455
GS08
✽ Responsible ✽
Agency Code
M
ID
1/2
142
GS03
✽ Application ✽
Send’s Code
AN 2/15
M
AN 2/15
GS04
373
Date
✽
M
DT
GS05
✽
8/8
337
Time
M
TM
GS06
✽
4/8
28
Group Ctrl
Number
M
N0
1/9
480
Ver/Release
ID Code
M
124
Application
Rec’s Code
~
AN 1/12
ELEMENT SUMMARY
USAGE
REQUIRED
REF.
DES.
GS01
DATA
ELEMENT
479
NAME
ATTRIBUTES
Functional Identifier Code
M
ID
2/2
Code identifying a group of application related transaction sets
CODE
HI
REQUIRED
GS02
142
DEFINITION
Health Care Services Review Information (278)
Application Sender’s Code
M
AN
2/15
Code identifying party sending transmission; codes agreed to by trading partners
Use this code to identify the unit sending the information.
1000009
REQUIRED
GS03
124
Application Receiver’s Code
M
AN
2/15
Code identifying party receiving transmission. Codes agreed to by trading partners
Use this code to identify the unit receiving the information.
1000010
REQUIRED
GS04
373
Date
M
DT
8/8
TM
4/8
Date expressed as CCYYMMDD
SEMANTIC:
Use this date for the functional group creation date.
1000011
REQUIRED
GS04 is the group date.
GS05
337
Time
M
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:
1000012
234
GS05 is the group time.
Use this time for the creation time. The recommended format is
HHMM.
Original Page Number B.8 dated May 2000
OCTOBER 2002
ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
REQUIRED
GS06
28
004010X094A1 • 278 • GS
FUNCTIONAL GROUP HEADER
Group Control Number
M
N0
1/9
Assigned number originated and maintained by the sender
The data interchange control number GS06 in this header must be
identical to the same data element in the associated functional group trailer,
GE02.
SEMANTIC:
REQUIRED
GS07
455
Responsible Agency Code
M
ID
1/2
Code used in conjunction with Data Element 480 to identify the issuer of the
standard
CODE
X
REQUIRED
GS08
480
DEFINITION
Accredited Standards Committee X12
Version / Release / Industry Identifier Code
M
AN
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
CODE
New code value
1091
OCTOBER 2002
DEFINITION
004010X094A1 Draft Standards Approved for Publication by ASC
X12 Procedures Review Board through October
1997, as published in this implementation guide.
When using the X12N Health Care Services Review —
Request for Review and Response Implementation
Guide, originally published May 2000 as 004010X094
and incorporating the changes identified in the
Addenda, the value used in GS08 must be
“004010X094A1”.
Original Page Number B.9 dated May 2000
235
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ASC X12N • INSURANCE SUBCOMMITTEE
IMPLEMENTATION GUIDE
1968 Green Road
Ann Arbor, MI 48105
ABSTRACT
The International Classification of Diseases, 9th Revision, Clinical Modification,
describes the classification of morbidity and mortality information for statistical
purposes and for the indexing of hospital records by disease and operations.
New Code Set
132
National Uniform Billing Committee (NUBC) Codes
SIMPLE DATA ELEMENT/CODE REFERENCES
235/RB, 235/NU, 1270/BE, 1270/BG, 1270/BH, 1270/BI
SOURCE
National Uniform Billing Data Element Specifications
AVAILABLE FROM
National Uniform Billing Committee
American Hospital Association
840 Lake Shore Drive
Chicago, IL 60697
ABSTRACT
Revenue codes are a classification of hospital charges in a standard grouping
that is controlled by the National Uniform Billing Committee. Place of service
codes specify the type of location where a service is provided.
134
National Drug Code
SIMPLE DATA ELEMENT/CODE REFERENCES
235/ND, 1270/NDC
SOURCE
Blue Book, Price Alert, National Drug Data File
AVAILABLE FROM
First Databank, The Hearst Corporation
1111 Bayhill Drive
San Bruno, CA 94066
ABSTRACT
The National Drug Code is a coding convention established by the Food and
Drug Administration to identify the labeler, product number, and package sizes of
FDA-approved prescription drugs. There are over 170,000 National Drug Codes
on file.
236
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IMPLEMENTATION GUIDE
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HEALTH CARE SERVICES REQUEST FOR REVIEW AND RESPONSE
Health Care Financing Administration National PlanID
SIMPLE DATA ELEMENT/CODE REFERENCES
66/XV
SOURCE
PlanID Database
AVAILABLE FROM
Health Care Financing Administration
Center for Beneficiary Services
Administration Group
Division of Membership Operations
S1-05-06
7500 Security Boulevard
Baltimore, MD 21244-1850
ABSTRACT
The Health care Financing Administration is developing the PlanID, which will be
proposed as the standard unique identifier for each health plan under the Health
Insurance Portability and Accountability Act of 1996.
New Code Set
663
Logical Observation Identifier Names and Codes
(LOINC)
SIMPLE DATA ELEMENT/CODE REFERENCES
128/LOI, 235/LB, 1270/LOI
SOURCE
Logical Observation Identifier Names and Codes (LOINC)
AVAILABLE FROM
Reginstriff Institute
Indiana University School of Medicine
1001 West 10th Street
5th Floor RHC
Indianapolis, IN 46202
ABSTRACT
List of descriptive terms and identifying codes for reporting precise test methods
in medicine.
URL
http://www.mcis.duke.edu/standards/termcode/loinc.htm
OCTOBER 2002
Original Page Number C.8 Dated May 2000
237
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IMPLEMENTATION GUIDE
OCTOBER 2002
| File Type | application/pdf |
| File Modified | 2002-10-31 |
| File Created | 2001-08-31 |