Business Scenario - Referral request that was rejected for OON

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

HL*3*2*22*1~

Subscriber Loop

NM1*IL*1*SUBLASTNAME*SUBFIRSTNAME****MI*MEMBERID#~

Member Data

DMG*D8*19560708*M~

HL*4*3*23*1~

Dependent Loop

NM1*QC*1*DEPLASTNAME*DEPFIRSTNAME~

Dependent Data

DMG*D8*19580508*F~

HL*5*4*EV*1~

Event Loop

UM*SC*I**11:B~

Specialty Care Review, Initial, Office

DTP*AAH*D8*20200702~

Event Date =7/2/20

HI*ABF:G8929~

Diagnosis

MSG*PLEASE CALL WIH RESULTS~

Additional information

NM1*SJ*2*CARDIOLOGY OF TULSA*****XX*1234567888~

Event Provider role identification

HL*6*5*SS*0~

Service Loop

SV1*HC:99212~

PX code = 99212 to be completed x10 to begin on 07/02/2020

HSD*VS*10~

HL*7*5*SS*0~

Service Loop

SV1*HC:93530~

PX code = 93530 to be completed x1 to begin on 07/02/2020

HSD*FL*1~

SE*25*1001~

Outbound Transmission Explanation

ST*278*0001*008010X342~

Submitter transaction Identifier

BHT*0007*11*16139462398*20200624*07344807*18~

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*SUBLASTNAME*SUBFIRSTNAME****MI*MEMBERID#~

Member Data

DMG*D8*19560708*M~

HL*4*3*23*1~

Dependent Loop

NM1*QC*1*DEPLASTNAME*DEPFIRSTNAME~

Dependent Data

DMG*D8*19580508*F~

HL*5*4*EV*1~

Event Loop

HCR*A3**25~

Default HCR segment

UM*SC*I**11:B~

Specialty Care Review, Initial, Office

DTP*AAH*D8*20200702~

Event Date=7/2/20

HI*ABF:G8929~

Diagnosis

NM1*SJ*2*CARDIOLOGY OF TULSA*****XX*1234567888~

Event Provider role identification

AAA*N**35*C~

AAA=35 (Out of Network)

SE*24*0001~