ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
Example 6b: Response to Medical Services Reservation
The following example represents the response to the Medical Service Reservation from ABC Payer to Dr. Gardner.
In this case ABC Payer has accepted a reservation for patient Joe Smith for procedure code 99212. The unit count requested and accepted is 1. The remaining medical services on file with ABC Payer is 2.
Transmission Explanation
Table 1
ST*278*0001*005010X217~
Begin transaction set 278, control #0001, and the implementation convention reference is 005010X217.
BHT*0007*11*5269367*20050502*0859*RU~
This transaction is a Medical Services Reservation response using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier 5269367 along with the transaction 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*ABC PAYER*****PI*1234560010~
The response for the Medical Services Reservation is being made by ABC Payer. Their Electronic Transmitter Identification Number is 1234560010.
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. The HL code is 21, identifying the information receiver or the requesting provider. This HL has subordinate levels, or children.
NM1*1P*1*GARDNER*JAMES****24*0010102364~
The response is being sent to James Gardner whose Employer’s Identification Number is 0010102364.
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*12345689001~
The patient’s name is Joe Smith; his Member Identification Number is 12345689001.
DMG*D8*19580322*M~
The patient’s date of birth is March 22, 1958.
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.
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*IN*I*1*11:B~
This identifies that this is a Medical Services Reservation for a Medical Care service with a Place of Service of 11 (office).
HCR*A1*6735172961~
This service was certified in total with a confirmation or certification number of 6735172961.
Loop 2000F hierarchical level identifies the services associated with this event.
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 specific services associated to this request. This HL has no subordinate levels, or children.
DTP*472*D8*20050110~
The proposed date for the service reservation is January 10, 2005.
SV1*HC:99212**UN*1~
The Medical Service Reservation response identifies that procedure code 99212 for a unit count of 1 has been reserved for this patient.
HSD*****29*2~
The remaining number of services on file for this patient is 2.
SE*17*0001~
Number of segments, control number.