Example 04: Request for Home Health Care

Transmission Explanation

Table 1

ST*278*0001*005010X217~

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

BHT*0007*13*B56789*20050502*1430~

This transaction is a request using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier “B56789" along with the transaction set creation date and time.

Loop 2000A hierarchical level identifies the insurance company.

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*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~

The request for a health service review and an admission review is being made to Maryland Capital Insurance Company. Their electronic transmitter identification number is 789312.

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. This HL code is 21, identifying the information receiver or the referring provider. This HL has subordinate levels, or children.

NM1*1P*1*WATSON*SUSAN****34*98765432~

The request is being made by Susan Watson whose Social Security Number is 98765432.

PER*IC**TE*4029993456~

Dr. Watson can be contacted by telephone at (402)999-3456.

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*12345678901~

The patient’s name is Joe Smith; his Member Identification Number is 12345678901.

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 level.

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*HS*I**12:B*****Y~

This is an initial request for home care. Appropriate release of information is on file at the health service provider or at the utilization review organization.

HI*BF:1831*BF:2630~

The patient has been diagnosed with ovarian cancer - malignant neoplasm of ovary and malnutrition of moderate degree.

HSD*VS*3*WK**34*2~

The patient will receive services over a 2 month period delivered 3 times per week.

CR6*1*20050502*RD8*20050502-20050801***W*I~

The patient’s prognosis is poor. The requested home health care is scheduled to begin on May, 2005 and extend to August 1, 2005. The patient is not in a skilled nursing facility and not on Medicare.

NM1*SJ*2*CARING HANDS HOME HEALTH AGENCY*****24*345678912~

Caring Hands Home Health Agency will provide the care.

The loop below allows the provider to request authorization for specific procedure codes. In this example, the request includes 2 procedure codes identified below. Therefore, the request includes 2 occurrences of Service level Loop 2000F.

Loop 2000F hierarchical level identifies the service level. Loop 2000F repeats for each service.

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 service. This HL has no subordinate levels, or children.

SV1*HC:G0154~

HCPCS/CPT for Services of skilled nurse in home care setting.

HL*6*4*SS*0~

HL count is 6. This HL is subordinate to HL*4, the parent HL. This HL code is SS, identifying the service. This HL has no subordinate levels, or children.

SV1*HC:B4184~

HCPCS/CPT for Parenteral nutrition - 10% lipids.

SE*19*0001~

Number of segments, control number.