ASC X12 Version: 008010 | Transaction Set: 278 | TR3 ID: 008010X342
Business Scenario - Medical Drug request
A Provider submits an initial medical drug request using the X342 8010 version.
Inbound Transmission Explanation
ST*278*1001*008010X342~
Submitter transaction Identifier
BHT*0007*13*16139462398*20200624*0734~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity
PER*IC*CONTACT NAME*TE*5556368147*EX*551~
Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
UM*HS*I**12:B**E~
Health Services, Initial, Home, Elective
DTP*AAH*D8*20200702~
Event Date=7/2/20
HI*ABF:M069~
Diagnosis
MSG*ADDITIONAL INFORMATION CAN BE PROVIDED IN MSG~
Additional information
NM1*71*1*PROVIDER*ATTENDING****XX*1234567899~
Event Provider role identification
NM1*SJ*2*ABC HOME DRUG SPECIALTY*****XX*1234567888~
HL*5*4*SS*0~
Service Loop
UM*HS*I~
DTP*472*RD8*20200702-20201002~
Service Date to begin on 07/02/2020
DRA*INFLIXIMAB 10 MG*I*N4:57894003001*UN*20*INFUSE OVER AT LEAST 2 HOURS. BEGIN AT 40 ML/HR FOR 15 MINUTES, THEN INCREASE RATE TO 80 ML/HR FOR 30 MINUTES. IF TOLERATED INCREASE TO 160 ML/HR FOR THE DURATION OF INFUSION*N*N******43~
DRA segment to report drug details
SE*22*1001~
Outbound Transmission Explanation
ST*278*0001*008010X342~
Submitter transaction Identifier
BHT*0007*11*16139462398*20200624*07344807*19~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
UM*HS*I**12:B**E~
Health Services, Initial, Home, Elective
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
DTP*AAH*D8*20200702~
Event Date=7/2/20
HI*ABJ:M069~
Diagnosis
NM1*71*1*PROVIDER*ATTENDING****XX*1234567898~
Event Provider role identification
NM1*SJ*2*ABC DME EQUIPMENT*****XX*1234567888~
HL*5*4*SS*0~
Service Loop
UM*HS*I~
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
DTP*472*RD8*20200702-20201002~
Service Date to begin on 07/02/2020
DRA*INFLIXIMAB 10 MG*I*N4:57894003001*UN*20*INFUSE OVER AT LEAST 2 HOURS. BEGIN AT 40 ML/HR FOR 15 MINUTES, THEN INCREASE RATE TO 80 ML/HR FOR 30 MINUTES. IF TOLERATED INCREASE TO 160 ML/HR FOR THE DURATION OF INFUSION*N*N******43~
DRA segment to report drug details
SE*24*0001~