278 Health Care Services Review Information – definition and purpose
The 278 Health Care Services Review Information transaction belongs to HIPAA EDI documents. A health organization can send 278 Health Care Services Review Information (patient data, diagnosis or treatment data) for the purposes of requesting a review. Typically the requestor (the sending party) is the health care provider and the receiver is the payer (insurance company) The 278 Health Care Services Review Information can also report the outcome of a review. For example a hospital will send a patient admission notice or a patient discharge notice via a 278. Another example is to send dental referrals via the 278. An additional example is health care provider requesting a certification for a patient to receive health care services.
278 Health Care Services Review Information Purpose & Scope
The 278 can be sent as an unsolicited one-way transaction or it can be sent/received as a turn-around transaction. Utilization Management Organizations (UMO) play a key role in this transaction frequently; they monitor health care provided by others. Examples of a UMO are HMOs, insurance companies, PPOs and etc.
A best practice to consider when using this transaction is to send a separate 278 for each patient and each patient event. Unlike other health care transactions, this one can be considered a one-to-one relationship instead of a one-to-many relationship transaction. Another excellent feature of the 278 is the capability to send supplemental attachments in the PWK segment. The PWK segment can be used to refer to an attachment
278 Health Care Services Review Information related transaction is the 270/271 document. The 270/271 transaction help establish eligibility information, and the 278 transaction should not be used to request eligibility inquiries.
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