Business Scenario - Notification of Admission submission

Inbound Transmission Explanation

ST*278*44789*008010X328~

Submitter transaction identifier

BHT*0007*CN*123456789*20200518*001631*NO~

HL*1**20*1~

Information Source Loop

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

PER*IC*UTILIZATION REVIEW*TE*2547245770~

Contact Name and other information

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*M~

HL*4*3*EV*0~

Event Loop

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

Admission, Initial, Medical, IP Hospital, Emergency

DTP*435*D8*20200702~

Admission Date =7/2/20

HI*ABJ:K922~

Admitting Diagnosis

HSD*DY*1~

Length of Stay

CL1***1~

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

N3*3500 GASTON AVE~

N4*DALLAS*TX*752462017~

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

Event Provider role identification

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~

N3*3500 GASTON AVENUE~

N4*DALLAS*TX*75246~

PER*IC**TE*2148202319~

PRV*AT*PXC*207P00000X~

SE*30*44789~

Outbound Transmission Explanation

ST*278*0001*008010X328~

Submitter transaction identifier

BHT*0007*53*123456789*20200518*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*M~

SE*11*0001~