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 send and receive notifications 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 notification. The intention of the developers of the 278 is represented in this guide.

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This implementation guide is designed to assist those who send, receive and/or route notifications associated with health care review outcomes that include the following:

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  • Advance Notification of authorizations for planned or scheduled admissions, health services, specialty referrals.

  • Completion Notification of admissions and discharges that have occurred or the completion of the delivery of previously authorized health care services.

  • Information Copy or courtesy copy to notify a receiving entity of a health care services review outcome.

  • Acknowledgment of receipt of a health care services review notification or information copy.

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Notifications do not necessarily require a response because the decision outcome has already been established. Similarly, an information copy does not require verification, or approval. However this guide does provide the ability to respond to a notification or information copy specifically to acknowledge receipt of the transmission and to address error conditions identified during application layer processing.

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Health care entities that use this implementation of the 278 include, but are not limited to the following:

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  • Utilization Management Organizations (UMOs) (e.g., insurance companies, health maintenance organizations, preferred provider organizations, health care purchasers, professional review organizations, other providers, and other utilization review entities) that send, or receive notifications regarding Health Care Services review information.

  • Providers (e.g., physicians, medical groups, independent physician associations, facilities) who send notifications regarding Health Care Services review information to UMOs, or to other providers.

  • Providers who receive notifications.

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