Example 6a: Request for Medical Services Reservation

Transmission Explanation

Table 1

ST*278*0001*005010X217~

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

BHT*0007*13*5269367*20050502*2243*RU~

This transaction is a Medical Services Reservation request using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier 5269367 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 the Medical Services Reservation is being 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*GARDNER*JAMES****24*0010102364~

The request is being made by James Gardner whose Employer’s Identification Number is 0010102364.

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.

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*IN*I*1*11:B~

Dr. Gardner is requesting an Initial Medical Services Reservation for a Medical Care service with a Place of Service of 11 (Office) for the patient.

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.

DTP*472*D8*20050510~

The proposed date for the service reservation is May 10, 2005.

SV1*HC:99212**UN*1~

Dr. Gardner is requesting a Medical Services Reservation for procedure code 99212, unit count 1.

SE*15*0001~

Number of segments, control number.