EDI 278 Transaction (Health Care Services Review Information)
The EDI 278 transaction, also known as the Health Care Services Review Information transaction, is a standard format used in healthcare EDI to request and communicate information related to the review of healthcare services. It is primarily used in the context of managed care and healthcare service authorization.
Here’s an overview of its key components:
- Purpose: The EDI 278 transaction is used to request and communicate information related to the review of healthcare services. This can include requests for authorization of medical services, referrals, certifications, and other types of healthcare service reviews.
- Sender and Receiver: The sender of the EDI 278 transaction is typically a healthcare provider or their authorized representative, such as a medical office or hospital. The receiver is usually an entity responsible for reviewing and processing healthcare service requests, such as a managed care organization, health insurance company, or third-party administrator.
- Data Elements: The EDI 278 transaction contains various data elements that convey information about the healthcare service being requested or reviewed. These data elements include patient information, provider information, service details (such as CPT or HCPCS codes), dates of service, clinical information, and other relevant details necessary for the review process.
- Authorization and Response: The EDI 278 transaction may include requests for authorization of specific healthcare services. Upon receiving a request, the receiver evaluates the request based on established criteria and guidelines. They then respond with an authorization decision, which may include approval, denial, modification, or other actions. This response is typically sent back to the sender in the form of an EDI 278 response transaction.
Overall, the EDI 278 transaction facilitates the electronic exchange of information related to the review and authorization of healthcare services, streamlining the process and improving efficiency in managed care and healthcare service management.