The EDI 278
transaction set is called Health Care Services Review Information. A healthcare provider, such as a hospital, will send a 278 transaction to request an authorization from a payer, such as an insurance company. The hospital is asking the insurance company to review proposed healthcare services to be provided to a given patient, in order to obtain an authorization for these services.
The 278 transaction can be used to submit information in the following categories:
- Advance notification – for scheduled inpatient, specialty care or other services
- Completion notification – for patient arrival to or discharge from a facility
- Information copy – for any health services review information sent to service providers
- Change notification – for reporting changes to previously sent information
A 278 may relate to services to be administered by the healthcare service provider, or for referring an individual to another provider. The transaction may also be used by the payer to respond to this request for an authorization. Thus, the 278 can be used either as a one-way transaction, or as a two-way “inquiry/response” type of transaction. Unlike other healthcare transactions that may be used in relation to multiple plan subscribers or patients, a single 278 is commonly used for one patient and one patient event.
The ANSI X12 EDI standards include three versions of the 278 transaction set. Of these, the Health Care Services Review and Response document was chosen by HIPAA as the standard format for EDI transmission of authorizations and referrals. This is an important issue of patient privacy, as 278 documents typically contain healthcare related data, such as patient, diagnosis or treatment information. As of March 31, 2012, healthcare providers must be compliant with version 5010 of the HIPAA EDI standards.
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This X12 Transaction Set contains the format and establishes the data contents of the Health Care Services Review Information Transaction Set (278) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to transmit health care service information, such as subscriber, patient, demographic, diagnosis or treatment data for the purpose of request for review, certification, notification or reporting the outcome of a health care services review.
Expected users of this transaction set are payors, plan sponsors, providers, utilization management and other entities involved in health care services review.