ASC X12 Version: 008010 | Transaction Set: 278 | TR3 ID: 008010X342
Business Scenario - Non Emergency Ambulance Transport request
A Provider submits an initial non-emergency ambulance transport request that includes pickup and drop off address locations 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*PROVIDER*ATTENDING****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**41:B~
Health Services, Initial, Ambulance
HI*ABF:R531*ABF:Z9981~
Diagnosis
CR1***X******DIALYSIS~
Ambulance Transport Code, Round Trip reason
MSG*PATIENT GOING M, W, F ROUND TRIP TO DIALYSIS FOR ONE MONTH~
Additional Information
NM1*1P*1*PROVIDER*ATTENDING****XX*1234567899~
NM1*SJ*2*AMBULANCE SERVICE OF AMERICA*****XX*1234567670~
Event Provider role identification
NM1*PW*2*AUTUMN HOME ON THE LAKE~
Ambulance Pickup and Final Destination addresses
N3*400 BRITTANY FARMS RD~
N4*NEW BRITAIN*AZ*06022~
NM1*FS*2*HOSPITAL OF NEW BRITAIN DIALYSIS~
N3*300 ELM STREET~
N4*NEW BRITAIN*AZ*06022~
HL*5*4*SS*0~
Service Loop
DTP*472*RD8*20200925-20201123~
SV1*HC:A0428~
PX code = A0428 to be completed x12 between dates 9/25/20 and 10/25/2020
HSD*FL*12~
SE*28*1001~
Outbound Transmission Explanation
ST*278*0001*008010X342~
Submitter transaction Identifier from request
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*PROVIDER*ATTENDING****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**41:B~
Health Services, Initial, Ambulance
HCR*A4**0V~
Certification Action Code
REF*NT*5976434110000000~
Administrative Reference number
HI*ABF:R531*ABF:Z9981~
Diagnosis
CR1***X~
Ambulance Transport Code, Round Trip reason
NM1*71*1*PROVIDER*ATTENDING****XX*1234567899~
NM1*SJ*2*AMBULANCE SERVICE OF AMERICA*****XX*1234567670~
Event Provider role identification
NM1*PW*2*AUTUMN HOME ON THE LAKE~
Ambulance Pickup and Final Destination addresses
N3*400 BRITTANY FARMS RD~
N4*NEW BRITAIN*AZ*06022~
NM1*FS*2*HOSPITAL OF NEW BRITAIN DIALYSIS~
N3*300 ELM STREET~
N4*NEW BRITAIN*AZ*06022~
HL*5*4*SS*0~
Service Loop
HCR*A4**0V~
Certification Action Code
REF*NT*5976434110000000~
Administrative Reference number
DTP*472*RD8*20200925-20201025~
SV1*HC:A0428~
PX code= A0428 to be completed x12 between dates 9/25/20 and 10/25/2020
HSD*FL*12~
SE*30*0001~