Business Scenario - Outpatient Knee Arthoscopy with Solicited Attachment

Inbound Transmission Explanation

ST*278*44789*008060X342~

Submitter transaction Identifier

BHT*0007*13*123456789*20240518*001631~

HL*1**20*1~

Information Source Loop

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

Contact Name and other information

HL*2*1*21*1~

Information Receiver Loop

NM1*1P*1*LASTNAME*FIRSTNAME****XX*1234567888~

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*1~

Event Loop

UM*HS*I*2*22:B**E~

Health Service Review, Initial, Surgical, OP Hospital, Elective

DTP*AAH*D8*20240702~

Event Date=7/2/24

HI*ABF:S8353~

Diagnosis

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

Event Provider role identification

N3*3500 GASTON AVE~

N4*DALLAS*TX*752462017~

HL*5*4*SS*0~

Service Loop

SV2**HC | 29888~

PX code: Arthroscopic ligament repair X1

HSD*FL*1~

SE*21*44789~

275 Inbound Transmission Explanation

ST*275*1234*008060X343~

Transaction Set Purpose was an Information Copy

BGN*11*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*2*5623558800000000-26257-6~

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

STC*R4:26257-6::LOI~

SVC*HC:29888*0~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*3117*Attachment Payload~

LX*2~

TRN*2*5623558800000001-52299-5~

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

STC*R4:52299-5::LOI~

SVC*HC:29888*0~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*277*Attachment Payload~

LX*3~

TRN*2*5623558800000002-11524-6~

STC*R4:11524-6::LOI~

SVC*HC:29888*0~

DTP*368*D8*20240520~

CAT*AE*IA~

OOI*1*47*ATTACHMENT~

BDS*B64*3117*Attachment Payload~

SE*30*1234~

Outbound Transmission Explanation

ST*278*0001*008060X342~

Submitter transaction Identifier from request

BHT*0007*11*123456789*20160502*05105949*19~

HL*1**20*1~

Payer Loop

NM1*X3*2*PAYER*****PI*PAYERID~

HL*2*1*21*1~

Requesting Entity Loop

NM1*1P*2*REQUESTINGNAME*****XX*NPI~

Requesting Entity

HL*3*2*22*1~

Subscriber Loop

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

Member Data

DMG*D8*19310131~

DMH*U~

HL*4*3*EV*1~

Event Loop

UM*HS*I**22:B**E~

HCR*A4**0U~

REF*NT*5623558800000000~

DTP*AAH*D8*20240702~

HI*ABF:S8353~

NM1*FA*2*FACILITY*****XX* FACILITYNPI~

HL*5*4*SS*0~

HCR*A4**0U~

HI*LOI:26257-6*LOI:52299-5*LOI:11524-6~

SV2**HC:29888~

HSD*FL*1~

PWK*UL****AC*5623558800000000-26257-6~

PWK*UL****AC*5623558800000001-52299-5~

PWK*UL****AC*5623558800000002-11524-6~

SE*26*0001~