Section title: X12 EDI Examples
back to previous

ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217

Example 1: Referral

This is an example of a standard Referral Request / Response sequence between a Primary Care Provider and a Utilization Management Organization. The example will show how a PCP can request a referral to a specialist for a patient from a UMO. The example will also show the response.

Joe Smith is a subscriber to Maryland Capital Insurance Company. During a regular physical, Dr. James Gardener, Joe’s primary care physician, diagnoses a potential heart problem. Dr. Gardener determines that it would be best to refer Joe to Dr. Susan Watson, a cardiologist, for a consultation.

Dr. Gardener is required by Maryland Capital Insurance to submit a request for review seeking approval to refer Joe to Dr. Watson.

After review, Maryland Capital approves the referral and responds.