ASC X12 Version: 005010 | Transaction Set: 278 | TR3 ID: 005010X217
Example 3a: Request for Behavioral Health Emergency Admission
The following example represents the Request for Review (Admission Review).
Begin transaction set 278, control #0001, and implementation convention reference is 005010X217.
This transaction is a request using hierarchical structure 0007 (information source, information receiver, subscriber, dependent, event, services). The originating system has assigned the Submitter Transaction Identifier “YZZ345" along with the transaction set creation date and time.
Loop 2000A hierarchical level identifies the Utilization Management Company.
HL count is 1. There is no higher, or parent, HL. This HL code is 20, identifying the information source or the insurance company. This HL has subordinate levels, or children.
NM1*X3*2*CAPITAL INSURANCE COMPANY*****46*789312~
The request for a referral is being made to Capital Insurance Company. Their electronic transmitter identification number is 789312.
Loop 2000B hierarchical level identifies the Information Requester.
HL count is 2. This HL is subordinate to HL*1, the parent HL. This HL code is 21, identifying the information receiver or the requesting provider. This HL has subordinate levels, or children.
The request is being made by General Hospital whose Electronic Transmitter Identification Number is 8189991234.
Loop 2000C hierarchical level identifies the subscriber, who in this case is also the patient.
HL count is 3. This HL is subordinate to HL*2, the parent HL. This HL code is 22, identifying the subscriber. This HL has subordinate levels, or children.
The patient’s name is Mary Smith; her Member Identification Number is 12345678901.
Loop 2000D hierarchical level identifies the dependent as a patient. Because there is no dependent in this example, there is no Loop 2000D.
Loop 2000E hierarchical level identifies the patient event.
HL count is 4. This HL is subordinate to HL*3, the parent HL. This HL code is EV, identifying the patient event. This HL has no subordinate levels, or children.
The requester’s system assigned the trace number YZZ099 to this service request.
Dr. Jones is requesting an initial emergency psychiatric admission for the patient.
The patient has been diagnosed with Bipolar I Disorder, Single Manic Episode, Severe Without Psychotic Features (296.03).
Dr. Jones has requested a stay of 3 days.
Admission type is New.
Loop 2010E identifies the providers associated with this the patient event.
The admitting facility is identified as General Hospital. The ETIN Number is 987654321.
The hospital can be contacted by telephone at (402)999-3456.
Dr Marcus Jones is the attending physician.
Dr. Jacob Brown will be responsible for Mary’s care for this inpatient stay.
Number of segments. Control number.