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X12 transaction guide · Healthcare and insurance

EDI 278 Health Care Services Review Information

The X12 document used to request a review of health care services, such as prior authorization or referral, and to report the outcome.

Sent by
Healthcare provider, or the payer or review organization when responding
Received by
Payer or utilization management organization, or the provider
Standard
ANSI ASC X12

What is an EDI 278?

The EDI 278 Health Care Services Review Information is the ANSI X12 transaction set used to transmit health care service information, such as subscriber, patient, diagnosis and treatment data, to request a review, certification or notification, or to report the outcome of a services review. Expected users include payers, plan sponsors, providers and utilization management organizations.

In practice the 278 is the electronic prior authorization and referral transaction. HIPAA designates it as the standard for these requests in the United States, and it is used both for the request and for the response.

How the EDI 278 worksDiagram of the EDI 278 Health Care Services Review Information. Healthcare provider, or the payer or review organization when responding sends it to payer or utilization management organization, or the provider. It usually follows 271. It is usually followed by 278 and 999. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level). 1 optional loops are listed by their first segment.How the EDI 278 worksHealth Care Services Review Information: who sends it, where it fits and what the standard marks required1 WHERE IT FITSUSUALLY FOLLOWS271Eligibility, Coverage orBenefit InformationEDI 278SENDERHealthcare provider, orthe payer or revieworganization whenrespondingRECEIVERPayer or utilizationmanagementorganization, or theprovider997 or 999 acknowledgment back, if the partners agreeUSUALLY FOLLOWED BY278Health Care ServicesReview Information999ImplementationAcknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDsISA … IEAFunctional group, ID code HIGS … GETransaction set 278ST … SEHEADINGBHTBeginning of Hierarchical TransactionDETAILRequired loop 2000 · repeats many timesHLHierarchical Level+ 1 optional loop, starting with:NM1Blue box: required loop. Optional loops are listed by the segment that starts them; when a loop is used, that first segment is required. Optional segmentsoutside loops are not drawn.Structure: required segments and loops in the X12 008010 listing for the 278. Your trading partner's implementation guide adds its own requirements.
How the EDI 278 worksDiagram of the EDI 278 Health Care Services Review Information. Healthcare provider, or the payer or review organization when responding sends it to payer or utilization management organization, or the provider. It usually follows 271. It is usually followed by 278 and 999. Inside the ISA, GS and ST envelopes, X12 release 008010 requires, in the heading: BHT (Beginning of Hierarchical Transaction) and detail: the required 2000 loop with HL (Hierarchical Level). 1 optional loops are listed by their first segment.How the EDI 278 worksHealth Care Services Review Information: whosends it, where it fits and what the standardmarks required1 WHERE IT FITSUSUALLY FOLLOWS271Eligibility, Coverage or BenefitInformationEDI 278SENDERHealthcareprovider, or thepayer or revieworganizationwhenrespondingRECEIVERPayer orutilizationmanagementorganization, orthe provider997 or 999 acknowledgment back, if the partnersagreeUSUALLY FOLLOWED BY278Health Care Services ReviewInformation999Implementation Acknowledgment2 WHAT X12 RELEASE 008010 REQUIRESInterchange: sender and receiver IDs (ISA… IEA)Functional group, ID code HI (GS … GE)Transaction set 278 (ST … SE)HEADINGBHTBeginning of HierarchicalTransactionDETAILRequired loop 2000 · repeatsmany timesHLHierarchical Level+ 1 optional loop, starting with:NM1Blue box: required loop. Optional loops are listedby the segment that starts them; when a loop isused, that first segment is required. Optionalsegments outside loops are not drawn.Structure: required segments and loops in the X12008010 listing for the 278. Your trading partner'simplementation guide adds its own requirements.

How to read this diagram: the top row shows who sends the 278, to whom, and which documents usually come before and after it. The lower part shows what X12 release 008010 itself requires: the envelopes around the 278 and the segments and loops the standard marks as required, area by area. Optional loops are listed by the segment that starts them rather than drawn in full. This is the standard's minimum, not a trading partner's requirement: each partner's implementation guide usually makes some optional loops mandatory, restricts the codes and may use a different release.

Expand diagram Download SVG

When it is used

  • Requesting prior authorization for a procedure
  • Requesting referrals to specialists
  • Notifying a payer of an admission

Where it fits in the document flow

Usually follows 271 Eligibility, Coverage or Benefit Information
This document 278 Health Care Services Review Information
Usually followed by 278 Health Care Services Review Information999 Implementation Acknowledgment

Structure

Mandatory segments in the 278 (X12 release 008010)

The segments X12 release 008010 marks as mandatory at their level, in order. Segments inside optional loops are needed only when the loop is used. This is the standard's requirement, not your trading partner's: each partner's implementation guide names the release it uses, adds the optional segments it requires and restricts the values. The requirement status comes from one published X12 reference listing and has not been checked against a second source.

  • ST
  • BHT
  • HL
  • NM1
  • SE

Practical example

The 278 in practice

A patient needs an MRI that their health plan requires to be authorized. The imaging center sends a 278 request with the patient, the ordering physician, the diagnosis and the planned procedure. The plan's 278 response approves the service with an authorization number, which the center then includes on the 837 claim.

Implementation

Implementation considerations for the 278

  • Check each payer's authorization rules, as requirements vary by plan and service.
  • Carry authorization numbers from the 278 response through to the claim.
  • Track pending requests so services are not delayed by missing responses.

How ECOM helps

Automate the 278 with ECOM

Industry

Healthcare

Secure B2B integration and file transfer for providers, suppliers, distributors and healthcare partners.

Solution

EDI Integration

Exchange X12 and EDIFACT documents with partners and integrate them directly with your ERP.

Service

Fully Managed EDI

ECOM operates your defined EDI services end to end under a service agreement.

More general questions about EDI are answered in the EDI FAQ.

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