Understand the X12 278 health care services review request and response transaction structure

Steps

1. Obtain the applicable X12 278 Health Care Services Review — Request and Response implementation guide from x12.org; note that X12 278 covers both the request (278-13) and response (278-11) in the same transaction set.
2. Review the transaction set structure: an ISA/GS interchange and group envelope, followed by the ST-SE transaction set wrapper, then the hierarchical level (HL) structure organizing payer, subscriber, dependent, and service information into loops.
3. Study Loop 2000A (payer information), 2000B (subscriber), 2000C (dependent if applicable), 2000D (service provider), 2000E (facility if applicable), and 2000F (services requested) to understand the hierarchical parent-child relationships via HL04 (parent HL ID).
4. Review the UM (health care services review information) segment at Loop 2000F, which specifies the request category code (UM01), certification type (UM02), service type (UM03), and level of service (UM06).
5. Review the 278 response structure: HCR (health care services review information) segment in the response returns the action code (A1 certified, A3 not certified, A4 pended), and TR3 (trace number) for tracking.
6. Map denial codes and pend codes from HCR01 and associated message text segments to your system's authorization status model and implement handling for each action code category.