Example 2a: Admission Request for Review

Transmission Explanation

Table 1

ST*278*0001*005010X217~

Begin transaction set 278, control #0001, and implementation convention reference is 005010X217.

BHT*0007*13*B56789*20050502*1430~

This transaction is a request using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier “B56789" along with the transaction set creation date and time.

Loop 2000A hierarchical level identifies the insurance company.

HL*1**20*1~

HL count is 1. There is no higher, or parent, HL. This HL code is 20, identifying the information source or the insurance company. This HL has subordinate levels, or children.

NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~

The request for a health service review and an admission review is being made to Maryland Capital Insurance Company. Their electronic transmitter identification number is 789312.

Loop 2000B hierarchical level identifies the submitting provider.

HL*2*1*21*1~

HL count is 2. This HL is subordinate to HL*1, the parent HL. This HL code is 21, identifying the information receiver or the referring provider. This HL has subordinate levels, or children.

NM1*1P*1*WATSON*SUSAN****34*98765432~

The request is being made by Susan Watson whose Social Security Number is 98765432.

PER*IC**TE*4029993456~

Dr. Watson can be contacted by telephone at (402)999-3456.

Loop 2000C hierarchical level identifies the subscriber, who in this case is also the patient.

HL*3*2*22*1~

HL count is 3. This HL is subordinate to HL*2, the parent HL. This HL code is 22, identifying the subscriber. This HL has subordinate levels, or children.

NM1*IL*1*SMITH*JOE****MI*12345678901~

The patient’s name is Joe Smith; his Member Identification Number is 12345678901.

Loop 2000D hierarchical level identifies the dependent as a patient. Because there is no dependent in this example, there is no Loop 2000D.

Loop 2000E hierarchical level identifies the patient event.

HL*4*3*EV*1~

HL count is 4. This HL is subordinate to HL*3, the parent HL. This HL code is EV, identifying the patient event. This HL has subordinate levels, or children.

TRN*1*97021001*9012345678~

The provider assigned the trace number of 97021001 to this patient event request. The requester has included the user-assigned identifier of 012345678 to this trace number.

UM*AR*I*2*21:B*****Y~

Dr. Watson is requesting an admission review for the patient at an inpatient hospital setting.

DTP*435*D8*20050516~

Dr. Watson requests an admission date of May 16, 2005.

HI*BF:41090:D8:20050125~

The patient has been diagnosed with acute myocardial infarction; unspecified site.

HSD*DY*7~

Dr. Watson has requested certification for a length of stay of seven days.

CL1*2~

Dr. Watson indicates that the inpatient admission type is “urgent”.

NM1*FA*2*MONTGOMERY HOSPITAL*****24*000012121~

The admitting facility is identified as Montgomery Hospital. The Employer’s Identification Number is 000012121.

N3*475 MAIN STREET~

Montgomery Hospital street address.

N4*ANYTOWN*PA*19087~

Montgomery Hospital city, state, ZIP Code.

Loop 2000F hierarchical level identifies the services. Loop 2000F repeats for each service to be performed at Montgomery Hospital for which authorization is requested.

HL*5*4*SS*0~

HL count is 5. This HL is subordinate to HL*4, the parent HL. This HL code is SS, identifying the service. This HL has no subordinate levels, or children.

UM*HS*I*2~

Dr. Watson is requesting an initial health service review for surgery for the patient.

DTP*472*D8*20050516~

Dr. Watson is requesting permission to perform a triple bypass venous graft (CPT) on May 16, 2005.

SV2**HC:33510~

Dr. Watson is requesting permission to perform a triple bypass venous graft (CPT).

NM1*SJ*1*WATSON*SUSAN****34*987654321~

The service provider, the surgeon, is identified as Susan Watson. Her Social Security Number is 987654321.

PRV*PE*PXC*203BS0133X~

This segment identifies Dr. Watson’s specialty, thoracic cardiovascular surgery.

SE*26*0001~

Number of segments, control number.