Business Scenario - Notification of Admission submission with Unsolicited attachment

Inbound Transmission Explanation

ST*278*44789*008060X328~

Submitter transaction Identifier

BHT*0007*CN*123456789*20240518*001631*NO~

HL*1**20*1~

Information Source Loop

NM1*FA*2*FACILITY NAME*****XX*1234567888~

Contact Name and other information

PER*IC*UTILIZATION REVIEW*TE*2547245770~

HL*2*1*21*1~

Information Receiver Loop

NM1*PR*2*PAYER*****PI*12345~

HL*3*2*22*1~

Subscriber Loop

NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~

Member Data

DMG*D8*19470701~

DMH*M~

HL*4*3*EV*0~

Event Loop

UM*AR*I*1*11:A**03~

Admission, Initial, Medical, IP Hospital, Emergency

DTP*435*D8*20240702~

Admission Date=7/2/24

HI*ABJ:K922~

Admitting Diagnosis

HSD*DY*1~

Length of Stay

NM1*FA*2*FACILITY NAME*****XX*1234567888~

N3*3500 GASTON AVE~

N4*DALLAS*TX*752462017~

NM1*D0*1*PROVIDER*ADMITTING****XX*1234567999~

N3*3600 GASTON AVENUE*SUITE 550~

N4*DALLAS*TX*75246~

PER*IC**TE*2148203000~

PRV*AD*PXC*207R00000X~

NM1*71*1*PROVIDER*ATTENDING****XX*1234567898~

Event Provider role identification

N3*3500 GASTON AVENUE~

N4*DALLAS*TX*75246~

PER*IC**TE*2148202319~

PRV*AT*PXC*207P00000X~

HL*5*4*SS*0~

SV2*110*IP:0D184ZL~

HSD*FL*1~

PWK*AS*EL***AC*XXXXXXXXXX~

PWK*15*EL***AC*YYYYYYYYYYY~

PWK*UL*EL***AC*ZZZZZZZZZZZZ~

SE*36*44789~

275 Inbound Transmission Explanation

ST*275*1234*008060X343~

Transaction Set Purpose was an Information Copy

BGN*02*456789*20240520*0632~

NM1*ACV*1*PROVIDER*REQUESTING****XX*NPI*67*1P

Submitter of the additional information

NM1*40*2*PAYER NAME*****PI*PAYERID*67*PR ~

Receiver of the additional information

NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID

Member information

LX*1~

TRN*1*XXXXXXXXXX~

The Attachment Control Number (PWK06) that is on the 278 Date Additional Info was sent Category of the Attachment HL7 versus electronic image Admission Summary payload

SVC*IP:0D184ZL~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*3117*Attachment Payload~

LX*2~

TRN*1*YYYYYYYYYYY~

The Attachment Control Number (PWK06) that is on the 278 Date Additional Info was sent Category of the Attachment HL7 versus electronic image Justification for Admission payload

SVC*IP:0D184ZL~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*277*Attachment Payload~

LX*3~

TRN*1*ZZZZZZZZZZZZ~

SVC*IP:0D184ZL~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*3117*Attachment Payload~

SE*27*1234~

Outbound Transmission Explanation

ST*278*0001*008060X328~

Submitter transaction identifier from request

BHT*0007*53*123456789*20240518*00163353~

HL*1**20*1~

Payer Loop

NM1*FA*2*FACILITY NAME*****XX*1234567888~

HL*2*1*21*1~

Requesting Entity Loop

NM1*X3*2*AETNA*****PI*953402799~

Requesting Entity

HL*3*2*22*0~

Subscriber Loop

REF*BAF*1734122110000000~

NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~

Member Data

DMG*D8*19470701~

DMH*M~

SE*12*0001~