Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217

Example 05: Request for Non-emergency Transportation Service (Multi-destination Trip)

This is an example of a Health Care Services Review Request and Response between an ambulance service provider and a payer or Utilization Management Organization. The example will show how a provider can request a multi-destination non-emergency transportation service. The example will also show the response.

Joe Smith is a subscriber to ABC Payer. ABC Ambulance Service has been notified that they will be providing a multi-destination non-emergency transportation service to Mr. Smith, where the patient will be transported from home, to his physician’s office, to a dialysis center for treatment, then back home again.

ABC Ambulance Service is required to submit a request for approval of these non-emergency services showing each leg of the multi-destination trip and their association pick-up and drop-off locations prior to the service being provided to the patient.

After review, ABC Payer has approved this multi-destination non-emergency transportation trip and responds.