Where in the 278 can a provider indicate that a PA request is for urgent/expedited medical care? We have heard that 2000E UM06 in the Health Care Service Review Information is where a provider can signal the urgency of a PA request. However, how is a Level of Service Code a time sensitivity flag?
In this segment are three options:
03: Emergency
E: Elective
U: Urgent
If UM06 is the way to communicate turnaround times, it is in violation of federal law. Section 2719A of the Affordable Care Act (which came out in 2010 prior to the HIPAA mandate of 005010X278) prohibits the use of prior authorization in emergency situations. Further, if UM06 is how this information is communicated, why is there not "Routine"? Which is not the same as an "Elective" service.
UM06 does not seem to be the appropriate location to report this information. Free text would also not be appropriate as we want to automate this piece of the PA process. Is there somewhere else in the transaction to do this? This clarification is important given state and federal law have mandated timelines based on the urgency of a PA request. It is also troublesome that "Emergency" is listed in this transaction at all. Can a state assigned taxonomy code be submitted on the 837P and/or 837I?
A PA request is being sent and a provider wants to flag that this is a time sensitive request -- meaning an urgent/expedited service needs to be performed and the payer needs to respond within the timeframe dictated by State and/or Federal law.
The UM06 is the appropriate data element for the requester to report the “level of service”. When the level of service is considered to be routine, the UM06 data element would not be reported in the 278 Request as per the situational rule, “Required when UM02=1 or if the patient event requires a level of service for care other than routine. If not required by this implementation guide do not send.” When the level of service is other than routine (i.e., elective, urgent, emergency), or UM02 = 1, UM06 must be reported (as per the situational rule).
UM06 is not intended to report an expected “turn-around time’. It defines the level of service; State and/or Federal mandates specify the amount of time for a response to be returned (i.e., turn-around timeframe). It is not within X12’s purview to address state or federal requirements pertaining to turn-around times.
Taxonomy codes found in code source 682 are the only codes allowed on the 837P and 837I.