Chapter 1. Purpose and Business Information

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1.1 Implementation Purpose and Scope

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For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed to facilitate consistent implementation by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical.

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The purpose of this implementation guide is to provide standardized data requirements and content for all users who inquire on authorizations or certifications or who respond to such inquiries using the ASC X12, Health Care Services Review Information (278). This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for electronic health care service review inquiries and responses. The intention of the developers of the 278 is represented in this guide.

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This implementation guide is designed to assist providers who inquire about certification decisions (specialty care, treatment, admission) and the Utilization Management Organizations (UMO) who respond to those inquiries using the 278 format. In the context of this implementation guide, an inquiry refers to a transaction that asks for information on previously processed requests for authorization or certification.

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