ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
Example 2: Admission for Surgery
This is an example of a health services review request/response sequence between a specialist provider and a utilization management organization. The example shows how a specialist can request hospitalization for a patient from a UMO. The example also shows the UMO’s response.
Joe Smith is a subscriber to Maryland Capital Insurance Company. During a regular physical, Dr. James Gardener, Joe’s primary care physician, diagnosed a potential heart problem, acute myocardial infarction; unspecified site. Dr. Gardener had referred Joe to Dr. Susan Watson, a cardiologist for a consultation (see Business Scenario 1).
During the consultation examination, Dr. Watson determines that Joe’s diagnosis requires hospitalization and a surgical procedure, a triple bypass venous graft. The operation and recovery is to be at Montgomery Hospital.
Dr. Watson is required by Maryland Capital Insurance to submit a request for review seeking approval to perform the surgery at the hospital.
After review, Maryland Capital approves the request and responds.