Section title: Requests for Interpretation
Handling partial acceptance and partial denial within a X12 278 request

For an organization that receives prior authorizations from providers and provides determination back, how does the X12 standard handle partial acceptance and partial denial?


I am working with a payer group that receives prior authorizations from providers and sends back a determination.  For any given prior authorization, they may approve part of what is being requested but deny another portion.  They are required, by law, to respond to everything that has been requested.  For example, if a provider is seeking authorization for 10 of something and plan coverage only allows for 6, they need to still acknowledge the 4 that are denied.  Is anyone aware of the best way to handle this?  Should the payer deny the entire initial request for 10 with a note to resubmit for the amount that would be approved (i.e., 6)?  Or is there a way to approve part of a request and deny the other request within a single X12 278 response?

RFI Response

The current 278 transaction supports multiple response structures to report what services have been Certified in Total and Not Certified via the Service Level (2000F) service loops.  Approved services can utilize the HCR01=A1 for the number of services approved.  An additional service level loop can be used for the services that were Not Certified by using HCR01=A3 and HCR03 is populated with the reason some of the services were not approved.  If the response has both Certified in Total and Not Certified at the service levels, the Patient Event Detail (2000E) HCR01 should be A2 (Certified- Partial)

If only approving 6 out of the 10, some entities may only return just the service line of an HCR01=A1, or some may return an HCR01=A6 (Modified).