ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
Example 2b: Response to the Admission Request for Review
The following example represents the response to a request for review (health services review and hospital admission) from Maryland Capital Insurance to Dr. Watson.
In this case Maryland Capital Insurance is approving the request for surgery but partially approving the request for inpatient confinement.
Notice that the response transaction includes the detail of the request transaction to insure for all parties exactly what is being approved. Notice that the insurance company has included a certification number for reference, AUTH0002, for both services. The insurance company has the option of treating this as either one or two certifications.
Transmission Explanation
Table 1
ST*278*0001*005010X217~
Begin transaction set 278, control #0001, and the implementation convention reference is 005010X217.
BHT*0007*11*B56789*20050502*1431*18~
This transaction is a response using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The UMO’s system returns the Submitter Transaction Identifier “B56789". The BHT06 value of ”18" indicates that this is a response with no further updates to follow.
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*7893122~
The response to the request for admission review and health services review is being made by 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*987654~
The request is being made by Susan Watson whose Social Security Number is 987654321.
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*123456789011~
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*2*97021001*9012345678~
The UMO must return the trace number assigned by the provider to aid the provider in linking this service response to the original service request.
UM*AR*I*2*21:B~
Dr. Watson requested an admission review for the patient at an inpatient hospital setting.
HCR*A6*AUTH0002~
Maryland Capital has approved the inpatient stay but has approved a modification from the initial request.
DTP*435*D8*20050516~
Maryland Capital has approved the admission date of May 16, 2005.
HI*BF:41090:D8:20050125~
The patient has been diagnosed with acute myocardial infarction; unspecified site.
HSD*DY*5~
Dr. Watson requested certification for a length of stay of seven days. The UMO has certified a length of stay of five days.
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.
HCR*A1*AUTH0002~
Maryland Capital Insurance Company has approved the surgery in full and assigned the same certification number AUTH0002.
DTP*472*D8*20050516~
Dr. Watson requested permission to perform the procedure 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.
NOTE:
The CL1 segment is returned on the response only if it was valued on the request and used by the UMO when rendering a decision.