ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
Example 3b: Response to Request for Behavioral Health Emergency Admission
The following example represents the response to a request for review from Capital Insurance to General Hospital. In this case, Capital Insurance has pended the admission request for an admission summary to be delivered by telephone. Notice that the response transaction includes the detail of the request transaction to ensure for all parties exactly what is pended.
Transmission Explanation
Table 1
ST*278*0001*005010X217~
Begin transaction set 278, control #0001, and implementation convention reference is 005010X217.
BHT*0007*11*YZZ345*20050502*1102*19~
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 “YZZ345. The BHT06 value of ”19" indicates that this is a response with further updates to follow.
Loop 2000A hierarchical level identifies the Utilization Management 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*CAPITAL INSURANCE COMPANY*****46*789312~
The response to the request for an admission is being made by Capital Insurance Company. Their electronic transmitter identification number is 789312.
PER*IC**TE*3936533000~
The payer can be contacted by telephone at (393) 653-3000.
Loop 2000B hierarchical level identifies the Information Receiver.
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 requesting provider. This HL has subordinate levels, or children.
NM1*FA*2*GENERAL HOSPITAL*****46*8189991234~
The request is made by General Hospital whose Electronic Transmitter Identification Number is 8189991234.
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*MARY****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 is the patient event level.
HL*4*3*EV*0~
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 no subordinate levels, or children.
TRN*2*YZZ099*9876543210~
The UMO must return the trace number sent on the request to aid the provider in linking this response to the original request.
UM*AR*I*A4*21:B**03~
Dr. Jones submitted an initial request emergency psychiatric admission for the patient.
HCR*A4**0U~
Disposition is pending review.
REF*NT*P20030216001~
The UMO has assigned an administrative reference number to the review. The provider can use this number to reference this UMO response on subsequent inquiries associated with this pended health care services review.
HI*BF:29603:D8:20050429~
The patient has been diagnosed with Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features (296.03).
PWK*AS*VO~
Capital Insurance Company has requested an admission summary by voice.
NM1*FA*2*GENERAL HOSPITAL*****46*987654321~
The admitting facility is General Hospital. Its ETIN Number is 987654321.
NM1*71*1*JONES*MARCUS****24*453667654~
Dr Marcus Jones is the attending physician.
NM1*SJ*1*BROWN*JACOB****24*123454545~
Dr. Jacob Brown will be responsible for Mary’s care for this inpatient stay.
SE*20*0001~
Number of segments, control number