Example 5a: Request for Non-emergency Transportation

Transmission Explanation

Table 1

ST*278*0001*005010X217~

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

BHT*0007*13*165932*20050502*1525~

This transaction is a Health Care Services Review request for non-emergency transportation services using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier 165932 along with the transaction creation date and time.

Loop 2000A hierarchical level identifies the Insurance Company, UMO or Health Plan.

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*ABC PAYER*****PI*1234560010~

The request for review for the non-emergency transportation services is made to ABC Payer. Their Electronic Transmitter Identification Number is 1234560010.

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. The HL code is 21, identifying the information receiver or the requesting provider. This HL has subordinate levels, or children.

NM1*1P*1*XYZ AMBULANCE SVC*****24*7759621873~

The request is being made by XYZ Ambulance Svc whose Employer’s Identification Number is 7759621873.

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*12345689001~

The patient’s name is Joe Smith; his Member Identification Number is 12345689001.

REF*EJ*6532214A76~

The Patient Account Number for Joe Smith is 6532214A76.

DMG*D8*19580322*M~

The patient’s date of birth is March 22, 1958.

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.

UM*HS*I*56*41:B~

Dr. Gardner is requesting review and approval a multi-destination non-emergency transportation service for the patient. The Place of Service is 41 (Ambulance).

DTP*AAH*D8*20050510~

The date of this event is May 10, 2005.

CRC*07*Y*09~

The transportation conditions identified that the Ambulance was medically necessary (09).

CR1***X*D*DH*27***TRIP FROM HOME TO OFFICE VISIT TO DIALYSIS TREATMENT AND BACK HOME~

This multi-destination round trip is for a total of 27 miles. The trip is from the patient’s home, to an office visit, to a dialysis center for treatment, then back home again.

NM1*PW*2*HOME~

This identifies the pick-up destination is the patient’s home.

N3*8652 Starwood Lane~

The patient’s home address is 8652 Starwood Lane.

N4*SACRAMENTO*CA*95826~

The patient’s city, state and zip code are Sacramento, CA 95826.

NM1*ND*2*DR. GARDNER OFFICE~

This identifies the first stop in the multi-destination trip, Dr. Gardner’s office.

N3*1921 FULTON AVENUE~

The address of the patient’s physician office is 1921 Fulton Avenue.

N4*SACRAMENTO*CA*95624~

The city, state and zip code of the patient’s physician office are Sacramento, CA 95624.

NM1*R3*2*XYZ DIALYSIS CENTER~

This is the second stop in the multi-destination trip, the XYZ Dialysis Center.

N3*7622 MORSETOWN ROAD~

The address of the dialysis center is 7622 Morsetown Road.

N4*SACRAMENTO*CA*95826~

The city, state and zip code of the dialysis center are Sacramento, CA 95826.

NM1*FS*2*HOME~

This is the final destination in the multi-destination trip, back to the patient’s home.

N3*8652 Starwood Lane~

The patient’s home address is 8652 Starwood Lane.

N4*SACRAMENTO*CA*95826~

The patient’s city, state and zip code are Sacramento, CA 95826.

Loop 2000F hierarchical level identifies the services associated with this event.

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 specific services associated to this request. This HL has no subordinate levels, or children.

SV1*HC:A0428:RX**UN*5~

The ambulance company is requesting review and approval of procedure code A0428 for the first leg of the trip (home to physician office) for a total of 5 miles.

Repeat of Loop 2000F hierarchical level identifies the services associated with this event.

HL*6*5*SS*0~

HL count is 6. This HL is subordinate to HL *5, the parent HL. This HL code is SS, identifying the specific services associated to this request. This HL has no subordinate levels, or children.

SV1*HC:A0428:PD**UN*8~

The ambulance company is requesting review and approval of procedure code A0428 for the second leg (physician office to dialysis center) of the trip for a total of 8 miles.

Repeat of Loop 2000F hierarchical level identifies the services associated with this event.

HL*7*6*SS*0~

HL count is 7. This HL is subordinate to HL *6, the parent HL. This HL code is SS, identifying the specific services associated to this request. This HL has no subordinate levels, or children.

SV1*HC:A0428:DR**UN*14~

The ambulance company is requesting review and approval of procedure code A0428 for the final leg of the trip (dialysis center to home) for a total of 14 miles. The total trip equals 27 miles.

SE*34*0001~

Number of segments, control number.