278 Transaction example – raw data and human readable

278 TransactionThe following Raw Data and Human Readable examples of a 278 Transaction request for referral sent by provider Dr. Zoidberg to UMO INSURANCE R US. The document id for this 278 Transaction is 4158609887 found in BHT-03. The subscriber Fred Flintstone who happens to be the patient as well was diagnosed by Dr. Zoidberg on 2009-08-06 with Diagnosis code of 78550 found HI01-02 sub-element. Dr. Zoidberg is requesting referral to Dr. Armstrong for a one day consultation visit (UM and HSD segments) at Dr. Armstrong’s office.

278 Transaction Raw Data

NM1*X3*2*INSURANCE R US*****46*13579

278 Transaction Raw Data Human Readable

Beginning of Hierarchical Transaction: BHT*0078*13*4158609887*20120122*2204
Hierarchical Structure: Source, Receiver, Subscriber, Dependent, Provider of Service, Service
Transaction Set Purpose Code :’13’ for Request
Reference Identification : 4158609887
Date : 8/6/2009
Time : 10:04:00 PM
HL*1**20*1 –> information source

Individual or Organizational Name: NM1*X3*2*INSURANCE R US*****46*13579
Entity Identifier Code : Utilization Management Organization
Entity Type Qualifier : Non-Person Entity
Name Last or Organization Name : INSURANCE R US
Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
Identification Code : 13579
HL*2*1*21*1 Information Receiver

Individual or Organizational Name: NM1*1P*1*Zoidberg*John****46*12293
Entity Identifier Code : Provider
Entity Type Qualifier : Person
Name Last or Organization Name : Zoidberg
Name First : John
Identification Code Qualifier : Electronic Transmitter Identification Number (ETIN)
Identification Code : 12293
HL*3*2*22*1 Subscriber

Health Care Information Codes: HI*BF:78550:D8:20120122
Health Care Code Information : BF:78550
Date of Diagnosis: 8/6/2009
Individual or Organizational Name: NM1*IL*1*Flintstone*Fred****MI*MID987654321
Entity Identifier Code : Insured or Subscriber
Entity Type Qualifier : Person
Name Last or Organization Name : Flintstone
Name First : Fred
Identification Code Qualifier : Member Identification Number
Identification Code : MID987654321
HL*4*3*19*1 Provider of Service

Individual or Organizational Name: NM1*SJ*1*Armstrong*Edward*G***34*123456789
Entity Identifier Code : Service Provider
Entity Type Qualifier : Person
Name Last or Organization Name : Armstrong
Name First : Edward
Name Middle : G
Identification Code Qualifier : Social Security Number
Identification Code : 123456789
Contact Information: PER*IC**TE*8584537845
Information Contact :      Telephone : 8584537845
Provider Information: PRV*CO*ZZ*203BP0800Y
Provider Code : Consulting
Reference Identification Qualifier : Mutually Defined (Health Care Provider Taxonomy Code)
Reference Identification : 203BP0800Y
HL*5*4*SS*0 Hierarchy level for service (HL-03 = ‘SS’)

Trace: TRN*1*051036622050010*1262721578
Trace Type Code : Current Transaction Trace Numbers
Reference Identification : 051036622050010
Originating Company Identifier : 1262721578
Health Care Services Review Information:
Request Category Code : Specialty Care Review
Certification Type Code : Initial
Service Type Code : Consultation
Health Care Service Location Information : 11:B
Release of Information Code : Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data
Health Care Services Delivery: UM*SC*I*3*11:B
Quantity Qualifier : Visits (office visits UM04-01 = ’11’ for Office UM04-02 = ‘B’ for Place of service code)
Quantity : 1 (Number of office visits).

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