X12 Version: 008060 | Transaction Set: 278 | TR3 ID: 008060X342
Business Scenario - Admission request for a multiple birth newborn
A Provider submits an initial admission request for a multiple birth newborn using the X342 8060 version.
Inbound Transmission Explanation
ST*278*1001*008060X342~
Submitter transaction Identifier
BHT*0007*13*16139462398*20240624*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*SUBLASTNAME*SUBFIRSTNAME****MI*MEMBERID#~
Member Data
DMG*D8*19560708~
HL*4*3*23*1~
Dependent Loop
NM1*QC*1*DEPLASTNAME*BABY BOY 1~
Dependent data
DMG*D8*20240508~
DMH*M~
INS*N*19***************1~
INS used to describe Birth Sequence Number
HL*5*4*EV*0~
Event Loop
UM*AR*I*65*21:B~
Admission*Initial, Newborn Care, *IP Hospital
DTP*435*D8*20240702~
Admission Date=7/2/24
HI*ABJ:Z3868~
Admitting Diagnosis
HSD*DY*3~
Length of Stay
MSG*PROVIDER COMMENTS CAN GO HERE~
Additional information
NM1*71*1*PROVIDER*ATTENDING****XX*1234567898~
NM1*DO*1*PROVIDER*ADMITTING****XX*1234567899~
Event Provider role identification
NM1*FA*2*FACILITY NAME*****XX*1234567888~
SE*25*1001~
Outbound Transmission Explanation
ST*278*1001*008060X342~
Submitter transaction identifier
BHT*0007*11*16139462398*20240624*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 Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*SUBLASTNAME*SUBFIRSTNAME****MI*MEMBERID#~
Member Data
DMG*D8*19560708~
DMH*M~
HL*4*3*23*1~
Dependent Loop
NM1*QC*1*DEPLASTNAME*BABY BOY 1~
Dependent data
DMG*D8*20240508*M~
INS*N*19***************1~
INS used to describe Birth Sequence Number
HL*5*4*EV*1~
Event Loop
UM*AR*I**21:B~
Admission, Initial, IP Hospital
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
DTP*435*D8*20240702~
Admission Date=7/2/24
HI*ABJ:Z3868~
Admitting Diagnosis
NM1*71*1*PROVIDER*ATTENDING****XX*1234567898~
NM1*DO*1*PROVIDER*ADMITTING****XX*1234567899~
Event Provider role identification
NM1*FA*2*FACILITY NAME*****XX*12345678888~
HL*6*5*SS*0~
Service Loop
UM*HS*I*65~
HCR*A4**0V~
Certification Action Code
DTP*472*D8*20240702~
Service Type=Newborn Care to start on 07/02/2024
SE*29*1001~