Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response Chapter 7B 278 Health Care Services Request for Review and Response Trading partners use the ANSI ASC X12 278 Request for Review transaction to request review for specialty care, treatment, and admission. In response to the 278 Request, Anthem Health Plans of Virginia, Inc. (Anthem) replies with the ANSI ASC X12 278 Response transaction. NPI Data Elements The following 278 data elements are revised for NPI. In the 278 Request, carefully and accurately enter the values in these data elements. The charts in Sections 7.2 and 7.3 explain each of these data elements. Data Element Values Revised for NPI Loop(s) 278 Services Request for Review Data Element Notes 2010B (Requester Name) For most providers, NM108 (Identification Code Qualifier) = XX and NM109 (Requester Identifier) = NPI. 2010E (Service Provider Name) For most providers, NM108 (Identification Code Qualifier) = XX and NM109 (Provider Identifier) = NPI. 278 Services Review Response 2010B (Requester Name) This value will equal the value sent on the 278 Request. For most providers, NM108 (Identification Code Qualifier) = XX and NM109 (Provider Identifier) = NPI. 2010E (Service Provider Name) This value will equal the value sent on the 278 Request. For most providers, NM108 (Identification Code Qualifier) = XX and NM109 (Provider Identifier) = NPI. This Companion Document specifies 278 data elements that require instructions for Anthem. We do not include data elements that do need specific information for Anthem. Use this Companion Document in conjunction with the 278 Implementation Guide (IG). In accordance with the Basic Character Set documented in the Implementation Guide, format all alpha characters as uppercase only. For participating providers: Services subject to the FBPA (1999 Fair Business Practice Act – VA HB 2213) will be covered as long as the member’s Anthem coverage is active when the services are rendered, another payer is not responsible for payment of the claim and the information provided concerning the proposed treatment is accurate. Policy deductibles and co-payments always apply before final payment can be made, and prior services received by a member but not filed with the plan may affect our payment. Services not subject to FBPA are covered and paid based upon the terms of the member’s health care policy. IG Version 004010A1 (January 2009) Part II: 7-1 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response This Companion Document includes the following sections: Section Title Page 7.1 278 Request and Response: Basic Instructions 7-3 7.2 278 Request for Review Chart 7-7 7.3 278 Response Chart 7-26 7.4 278 Response AAA (Request Validation) Reject Reason Code Chart 7-32 IG Version 004010A1 (January 2009) Part II: 7-2 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.1 278 Request and Response: Basic Instructions This section provides information that trading partners need to understand before starting the 278 Request. The remaining sections of this Companion Document provide information about 278 Request and Response segments and data elements that require specific instructions for Anthem. Use the information in this Companion Document in conjunction with the 278 Implementation Guide including the 10/2002 Addenda. 7.1.1 Types of Health Care Services Reviews There are three major types of reviews covered by the 278 Request—Admission Review, Outpatient Review, and Specialty Care Review. Admission Review is the review of an inpatient stay. It includes a review of the facility stay and a review of the services to be provided by the physician. Outpatient Review is the review of specific outpatient services. Specialty Care Review (Referral) is a primary care physician’s recommendation for a patient to receive outpatient services from another provider (specialist). For information on key 278 data elements that specify each review type, see the introduction to Section 7.2, Request for Review. 7.1.2 Use Upper Case Alpha Characters in the 278 Request When entering alpha characters into the 278 Request, use only UPPERCASE alpha characters. As specified in the 278 IG, the basic character set of this standard includes uppercase letters, digits, space, and other special characters. For further information, see the 278 IG. 7.1.3 Attachments—PWK Segments When documentation is necessary to support a 278 Request, identify the documentation using the PWK (Paperwork) Segment, in loops 2000C (Subscriber Level), 2000D (Dependent Level), and 2000F (Additional Service Information). Trading partners separately fax or mail the actual supporting documentation. Information about contracts and services that require authorizations is available at www.anthem.com. Once on the site, select "Providers," then choose "Virginia." You will find a link to the Point of Care site on the Virginia home page. Use Message Text (MSG) Segments When Appropriate You may use the Message Text (MSG) segments in Loops 2000E and 2000F, if and when appropriate, to convey information about the 278 Request. This segment is limited to 264 bytes; so it will not accommodate information such as office notes, test results, etc. If you send an MSG segment, do not include characters used as delimiters. For example, if the pipe (|) is used as a subelement separator, do not use it in Free-Form Message text. IG Version 004010A1 (January 2009) Part II: 7-3 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response Attachment Procedure To identify and send attachments for 278 Requests, use the following procedure. 1. Create and transmit the 278 Request according to instructions in the IG and this Companion Document. In the appropriate PWK segment (either Loop 2000C, 2000D or 2000F), use the following data elements to identify that a paper attachment is forthcoming. PWK01, Attachment Report Type Code—Use the values indicated in the IG to identify the type of attachment. PWK02, Attachment Transmission Code—Use the following values indicated in the IG to identify how the attachment will be sent. The codes used by Anthem include: − AA (Available on Request at Provider Site) − BM (By Mail) − FX (By Fax) − VO (Voice) (Email is not available at this time.) PWK06, Attachment Control Number—Use if PWK02 equals BM or FX. 2. Prepare a cover sheet for each patient and 278 Request requiring supporting documentation. List the following information on the cover sheet: Your name, phone number (including area code), and your fax number Policyholder ID# Patient Name National Provider Identifier (NPI) Date of Service Attachment Control Number* *The Attachment Control Number must be a unique identifier for each 278 Request and it must match the number entered into PWK06 (Attachment Control Number). Construct the Attachment Control Number as indicated below: Attachment Control Number Member Identification # (Including any prefix) as shown on the ID card Distinctive Provider-Assigned Sequence Number or may remain unused. Recommendation: Use the Patient Control Number or other pertinent office identifier. 1234567890YTA123456789MMDDCCYYXXXXXXXXXX… National Provider Identifier (NPI) IG Version 004010A1 (January 2009) Date of Service Part II: 7-4 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response If the Attachment Control Number is not used, the 278 Request and the supporting documentation cannot be matched, possibly resulting in a certification denial. Multiple Attachments: When we need more than one supporting document for a 278 Request (such as Emergency Room and Operative Reports), use the same cover sheet to send all attachments. In this case, indicate on the cover sheet that there are multiple documents attached. Assign one attachment control number. Illegible information will delay processing. 3. Send the attachment using the sending method identified in PWK02. Please abide by the following guidelines when sending support documentation: Send attachments the day before or the day of submitting the 278 Request. Do not send a copy of claim with the attachment. Do not send unnecessary attachments. For example, do not send a copy of the member identification card. If you send supporting documentation by mail or fax, include the attachment control number in the upper right hand corner of the supporting documentation. Attach all documentation to the cover sheet. (Email is not available at this time.) Send the supporting documentation to the appropriate address or fax number below: For Medical, Surgical, and Maternity Services: Mailing Address: Anthem Blue Cross and Blue Shield Medical Management Mail Drop VA-44A P. O. Box 85638 Richmond, Va. 23286 Phone Number: (800) 242-7277 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2578 For Mental Health and Substance Abuse Services: IG Version 004010A1 (January 2009) Mailing Address: Anthem Blue Cross and Blue Shield Behavioral Healthcare Mail Drop VA-43M 2221 Edward Holland Drive Richmond, Va. 23230 Phone Number: (800) 991-6095 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2536 or (800) 876-6310 Part II: 7-5 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response Electronic Attachment 278 Requests Rejected Due to ANSI ASC X12N Compliance When a certification is rejected due to ANSI ASC X12N compliance, correct the 278 Request and use the same Attachment Control Number (2000F, PWK06) as used for the original 278 Request transmission. Because the supporting documentation was already mailed or faxed, we will hold it to match with the request once it is received. If a new Attachment Control Number is assigned for the retransmission of the 278 Request, you need to resubmit the supporting documentation and reference the new Attachment Control Number. What Happens When Necessary Attachments or Notes Are Not Provided? When a certification requires additional information that we have not received, we may review the Request and render a decision based on the information available. A “Not Certified” result may occur due to lack of information. 7.1.4 Disclaimer IG Version 004010A1 (January 2009) For participating providers: Services subject to the FBPA (1999 Fair Business Practice Act – VA HB 2213) will be covered as long as the member’s Anthem coverage is active when the services are rendered, another payer is not responsible for payment of the claim and the information provided concerning the proposed treatment is accurate. Policy deductibles and co-payments always apply before final payment can be made, and prior services received by a member but not filed with the plan may affect our payment. Services not subject to FBPA are covered and paid based upon the terms of the member’s health care policy. Part II: 7-6 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.2 278 Request for Review Trading partners use the ANSI ASC X12N 278 Request for Review transaction set to request review for specialty care, treatment, and admission. When creating a 278 Request for Review transaction, carefully follow the 278 IG and use the codes from the IG. We accept all ANSI ASC X12N compliant code sets. If some transactions within a functional group (GS/GE) pass Level 2 edits (checking for compliance with the Implementation Guide) and others do not, the Enterprise EDI Gateway removes the non-compliant transactions, adjusts the envelope segment count, and sends the functional group with the remaining valid transactions for processing. The Level 2 Status Report clearly reports transactions that passed and those that failed Level 2 editing. The 278 Request for Review transaction includes the following levels: The Header contains transaction control information. The Detail contains information for the transaction’s business function and includes the following levels: − Loop 2000A—Utilization Management Organization (UMO) − Loop 2000B—Requester − Loop 2000C—Subscriber − Loop 2000D—Dependent − Loop 2000E—Service Provider − Loop 2000F—Service There are three major types of reviews covered by the 278 Request—Admission Review, Outpatient Review, and Specialty Care Review. The explanations below define each type and identify the key 278 Request data element(s) which specify that type. Admission Review (Inpatient) Definition Admission Review is the review of an inpatient stay. It includes a review of the facility stay and a review of the services to be provided by the physician. Key Identifying Data Elements The following data elements identify the transaction as an Admission Review. Data Element Value 2000F (Service Level) Always indicates an Inpatient value UM04 (Facility Type Code) 2000F (Service Level) UM01 (Request Category Code) IG Version 004010A1 (January 2009) Part II: 7-7 AR (Admission Review) for the facility services HS (Health Care Services Review) for services rendered by the physician ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response Outpatient Review Definition Outpatient Review is the review of specific outpatient services. Key Identifying Data Elements The following data elements identify the transaction as an Outpatient Review. Data Element Value 2000F (Service Level) UM01 (Request Category Code) HS (Health Care Services Review) for outpatient services 2000F (Service Level) UM04 (Facility Type Code) Always indicates an Outpatient value AR (Admission Review) for to request a facility place of service if applicable Specialty Care Review Definition Specialty Care Review (Referral) is a primary care physician’s recommendation for a patient to receive outpatient services from another provider (specialist). Key Identifying Data Elements The following data elements identify the transaction as a Specialty Care Review. IG Version 004010A1 (January 2009) Data Element Value 2000F (Service Level) UM01 (Request Category Code) SC (Specialty Care Review) 2000F (Service Level) UM04 (Facility Type Code) Always indicates an Outpatient value Part II: 7-8 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.2.1 278 Request Header The 278 IG explains the 278 Header. No specific information is required from Anthem. Please follow the instructions in the 278 IG. 7.2.2 278 Request Utilization Management (UMO) Level Loop 2000A Loop 2000A, Utilization Management Organization (UMO), identifies Anthem as the UMO. The following chart explains the UMO data elements that require specific information for Anthem. Loop 2000A—UMO Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes Loop 2010A—Utilization Management Organization (UMO) Name NM1 NM102 Utilization Management Organization (UMO) Name Entity Type Qualifier 278 IG Page 55 UMO Last or Organization Name NM103 NM108 UMO Identifier NM109 2 Non-Person Entity ANTHEM HEALTH PLANS OF VIRGINIA INC 24 Employers Identification Number 54-0357120 Identification Code IG Version 004010A1 (January 2009) Part II: 7-9 This code represents Anthem Health Plans of Virginia, Inc. ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.2.3 278 Request— Requester Level Loop 2000B Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000B, Requester Level, identifies who is making the request and should receive the response. The following chart explains the Requester Level data elements that require specific information for Anthem. Loop 2000B—Requester Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes Only a patient’s primary care physician can request a Specialty Care Review. A facility or another provider cannot request a Specialty Care Review. Loop 2010B—Requester Name NM1 NM101 1P Provider Requester Name Entity Identifier Code FA Facility 278 IG Page 60 For a Specialty Care Review, if NM101 equals FA (Facility), we will reject the 278 Request.* NM103 See 278 IG We strongly recommend that you complete NM104 on every 278 Request. Requester Last or Organization Name NM104 If NM103 is not included, we will reject the 278 Request.* See 278 IG If NM101 equals 1P (Provider), then NM104 is required. If NM104 is not included, we will reject the 278 Request.* Requester First Name NM108 Identification Code Qualifier NPI Compliant: XX National Provider Identifier (NPI) NPI Exempt: 24 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) NM109 NPI Compliant: (NPI) Requester Identifier NPI Exempt: If NM108 = 24: (Employer’s Identification Number) If NM108 = 34: (Social Security Number) If NM108 = 46: (Electronic Transmitter Identification Number) Most trading partners enter XX. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. N3 We recommend completing address segments to identify the requester on all 278 Requests. Requester Address N301 278 IG Page 65 N4 See 278 IG Requester Address Line If this data element is not included, we will reject the 278 Request.* We recommend completing address segments to identify the requester on all 278 Requests. N401 See 278 IG Requester City/State/Zip Requester City Name Code N402 See 278 IG 278 IG Requester State or Page 66 Province Code If this data element is not included, we will reject the 278 Request.* If this data element is not included, we will reject the 278 Request.* * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-10 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Requester Level (2000B) 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2010B—Requester Name PER PER01 Requester Contact Information Contact Function Code 278 IG Page 68 Requester Contact Name PER02 PER03 IC Contact Information See 278 IG TE Telephone See 278 IG PER04 is required so we can direct responses for additional information. The value must include at least 10 digits. If PER04 is not included or includes less than 10 digits, we will reject the 278 Request.* EX Communication Number qualifier PER06 PER03 is required so we can direct responses for additional information. If PER03 is not included or includes less than 10 digits, we will reject the 278 Request.* Requester Contact Communication Number PER05 PER02 is required so we can direct responses for additional information. If PER02 is not included, we will reject the 278 Request.* Communication Number Qualifier PER04 PER01 is required. Telephone Extension We recommend completing PER05 if applicable. See 278 IG We recommend completing PER06 if applicable. See 278 IG PRV01 is needed to identify the requesting provider role. If PRV01 is not included, the 278 Request will be rejected. ZZ PRV02 is required. Requester Contact Communication Number PRV PRV01 Requester Provider Information Provider Code 278 IG Page 71 PRV02 Reference Identification Qualifier Mutually Defined. Health Care Provider Taxonomy Code List * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-11 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.2.4 278 Request Subscriber Level Loop 2000C Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000C, Subscriber Level, identifies the subscriber, who may or may not be the patient. 2000C is always required. If the subscriber is not the patient, then 2000C and 2000D (Dependent Loop) are both required. If the subscriber is the patient, only 2000C is required. The following chart explains the Subscriber Level data elements that require specific information for Anthem. Loop 2000C—Subscriber Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes Loop 2000C—Subscriber Level DTP Accident Date This segment is required if accident information is in 2000F (Service Level) UM05 (Related Causes Information). If not included for auto accident, we will reject the 278 Request.* 278 IG Page 75 HI HI01-1 Subscriber Diagnosis Diagnosis Type Code 278 IG Page 80 HI01-2 See 278 IG Diagnosis Code HI02 through HI12 See 278 IG PWK Additional Patient Information 278 IG Addenda Page 39 When the patient is the subscriber, we require a minimum of one diagnosis for all requests. These data elements indicate additional diagnoses. Include as appropriate. We can accept all 12 HI segments if applicable. When documentation is necessary to support a 278 Request, identify the documentation using this segment. You should mail or fax the actual supporting documentation. Information about contracts and services that require authorizations is available at www.anthem.com. Once on the site, select "Providers," then "Virginia," then “Answers@Anthem,” then “Specialty Care/Health Services.” PWK01 Attachment Report Type See 278 IG Use the values indicated in the IG to identify the type of attachment. * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-12 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Subscriber Level (2000C) 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000C—Subscriber Level (Continued) PWK02 PWK Attachment Report Type Code Additional Patient Information 278 IG Addenda Page 39 Codes used by Anthem include: AA Available on Request at Provider Site Email for supporting documentation is not available at this time. If you send supporting documentation by mail or facsimile, include a cover sheet listing the office contact name, phone number, fax number, policy number, patient name, date of service, provider number, and attachment control number. BM By Mail Illegible information will delay the 278 Response. FX By Fax For Medical, Surgical, and Maternity Claims: VO Voice Mailing Address: Anthem Blue Cross and Blue Shield Medical Management – Mail Drop VA-44A P. O. Box 85638 Richmond, Va. 23286 Phone Number: (800) 242-7277 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2578 For Mental Health and Substance Abuse Services: Mailing Address: Anthem Blue Cross and Blue Shield Behavioral Healthcare – Mail Drop VA-43M 2221 Edward Holland Drive Richmond, Va. 23230 Phone Number: (800) 991-6095 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2536 or (800) 876-6310 Loop 2010CA—Subscriber Name NM1 NM108 Subscriber Name Identification Code Qualifier 278 IG Addenda Page 44 NM109 Subscriber Primary Identifier MI Member Identification Number Enter the ID number as it appears on the front of the ID Card. Examples include: XXX######### XXXX######### XXX###X##### R######## If NM109 is not included, the patient is not eligible, or if there are errors in the entry, we will reject the 278 Request.* ID number formats will vary. The examples below show some common formats. Enter the ID number as it appears on the front of the ID card. Format Use for XXX######### XXX###X##### Alphanumeric All YTA123456789 except subscriber identi- AWSS123256999 fication number as FEP it appears on the YTA123X56789 front of the ID card R######## FEP XXXX######### Explanation R, then the 8-position numeric subscriber ID code. Examples R12345678 * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-13 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.2.5 278 Request Dependent Level Loop 2000D Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000D, Dependent Level, is required if the subscriber is not the patient. If the subscriber is the patient, this loop is not required. The following chart explains the Dependent Level data elements that require specific information for Anthem. Loop 2000D—Dependent Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes Loop 2000D—Dependent Level DTP Accident Date 278 IG Page 98 This segment is required if accident information is in 2000F (Service Level) UM05 (Related Causes Information). If not included for auto accident, we will reject the 278 Request. DTP01 439 Accident Date/Time Qualifier DTP02 Date Time Period Format Qualifier DTP03 D8 Date Expressed in Format CCYYMMDD If the diagnosis is related to an automobile accident, this segment is required. If not included for an automobile accident-related diagnosis, we will reject the 278 Request.* See 278 IG Accident Date HI HI01-1 Dependent Diagnosis Diagnosis Type Code 278 IG Page 103 HI12-2 See 278 IG When the patient is the dependent, we require a minimum of one diagnosis for all requests. HI01-1 and HI01-2 are required. If not included, we will reject the 278 Request.* Diagnosis Code HI02 through HI12 Use these data elements to indicate additional diagnoses. Include as appropriate. We can accept all 12 HI segments if applicable. PWK Additional Patient Information 278 IG Addenda Page 53 When documentation is necessary to support a 278 Request, identify the documentation using this segment. You should mail or fax the actual supporting documentation. Information about contracts and services that require authorizations is available at www.anthem.com. Once on the site, select "Providers," then "Virginia," then “Answers@Anthem,” then “Specialty Care/Health Services.” PWK01 Attachment Report Type See 278 IG Use the values indicated in the IG to identify the type of attachment. * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-14 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Dependent Level (2000D) 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) PWK02 Email for supporting documentation is not available at this time. PWK Attachment Report Type Code Codes used by Anthem include: Additional Patient Information 278 IG Addenda Page 39 AA Available on Request at Provider Site If you send supporting documentation by mail or facsimile, include a cover sheet listing the office contact name, phone number, fax number, policy number, patient name, date of service, provider number, and attachment control number. Illegible information will delay the 278 Response. BM By Mail For Medical, Surgical, and Maternity Claims: FX By Fax Mailing Address: VO Voice Anthem Blue Cross and Blue Shield Medical Management – Mail Drop VA-44A P. O. Box 85638 Richmond, Va. 23286 Phone Number: (800) 242-7277 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2578 For Mental Health and Substance Abuse Services: Mailing Address: Anthem Blue Cross and Blue Shield Behavioral Healthcare – Mail Drop VA-43M 2221 Edward Holland Drive Richmond, Va. 23230 Phone Number: (800) 991-6095 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2536 or (800) 876-6310 Loop 2010DA—Dependent Name NM1 NM103 Dependent Name Dependent Last Name 278 IG Addenda Page 58 NM104 DMG DMG02 Dependent Demographic Information Dependent Birth Date See 278 IG NM103 is required to identify the patient. If the patient is not the subscriber and this loop is not included, we will reject the 278 Request.* See 278 IG NM104 is required to identify the patient. If the patient is not the subscriber and this loop is not included, the dependent is not found, there is more than one match, or the dependent is not eligible, we will reject the 278 Request.* See 278 IG DMG02 is required to identify the patient. Dependent First Name 278 IG Addenda Page 62 * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-15 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.2.6 278 Request Service Provider Level Loop 2000E Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000E, Service Provider Level, identifies the service provider. The following chart explains the Service Provider Level data elements that require specific information for Anthem. The Service Provider Level includes either one or two loops as follows: For Admission Review: We require two 2000E loops, one to identify the facility and one to identify the admitting/attending physician. If more than two loops are submitted, we will reject the 278 Request.* We can accept only one servicing facility and one servicing provider per inpatient event. If more than one of each is submitted, we will reject the 278 Request.* For Specialty Care Review We can accept only one servicing provider per patient event. If more than one is submitted, we will reject the 278 Request.* For Outpatient Review: For outpatient surgery where there is a facility provider and a servicing provider, we can accept only one servicing facility and one servicing provider per patient event. If more than one of each is submitted, we will reject the 278 Request.* If the 278 Request is not for outpatient surgery, then only one 2000E loop is required. If more than one is submitted, we will reject the 278 Request.* 278 Service Provider Level (2000E) 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes Loop 2000E—Service Provider See 278 IG If you send this segment, do not include characMSG01 MSG ters used as delimiters. For example, if the pipe Free-Form Message Message Text (|) is a subelement separator, do not use it in Text 278 IG Free-Form Message text. Page 123 Loop 2010E—Service Provider Name See 278 IG We require NM103. If not included, we will reject NM1 NM103 the 278 Request.* Service Provider Service Provider Name Last or Organization Name 278 IG See 278 IG If NM102 (Entity Type Qualifier) equals 1 NM104 Page 124 (Person), NM104 is required. Service Provider First Name Most trading partners enter XX. NM108 NPI Compliant: Identification Code XX National Provider Identifier Examples of NPI exemptions include taxi Qualifier (NPI) services, home modifications, vehicle modifiNPI Exempt: cations, insect control, and respite services. 24 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) NM109 NPI Compliant: (NPI) Service Provider NPI Exempt: Identifier If NM108 = 24: (Employer’s Identification Number) If NM108 = 34: (Social Security Number) If NM108 = 46: (Electronic Transmitter Identification Number) * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-16 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Service Provider Level (2000E) 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2010E—Service Provider Name N3 We recommend completing address segments to identify the service provider on all 278 Requests. Service Provider Address N301 278 IG Page 129 N4 See 278 IG We require N301 is required. If it is not included, we will reject the 278 Request.* Service Provider Address Line We recommend completing address segments to identify the service provider on all 278 Requests. Service Provider N401 City/State/Zip Code Service Provider City Name 278 IG Page 130 N402 See 278 IG We require N401. If it is not included, we will reject the 278 Request.* See 278 IG We require N402. If it is not included, we will reject the 278 Request.* See 278 IG We recommend including N403. See 278 IG We recommend including PER02 if known TE We recommend including PER03 if known. Service Provider State or Province Code N403 Service Provider Postal Zone or Zip Code PER PER02 Service Provider Service Provider Contact Information Contact Name 278 IG Page 132 PER03 PER04 Service Provider Contact Communication Number PER05 Communication Number Qualifier PER06 Service Provider Contact Communication Number PRV Service Provider Information Telephone Communication Number Qualifier (Service Provider Telephone Number) We recommend including PER04. If known, enter the service provider telephone number, including the area code. EX We recommend including PER05 if applicable. Telephone Extension (Service Provider Telephone Number Extension) We recommend including PER06 if applicable. We strongly recommend completing this segment to assist in determining the provider’s role in the care of the patient. 278 IG Page 135 * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-17 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.2.7 278 Request Service Level Loop 2000F Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000F, Service Level, identifies the health care services requested. The following chart explains the Service Level data elements that require specific information for Anthem. Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE.. Segment Data Element Value Definitions and Notes Loop 2000F—Service Level UM UM01 See 278 IG Health Care Request Services Category Review Code Information 278 IG Page 141 For Admission Review and Outpatient Review: - Enter AR (Admission Review) to identify services by a facility. - Enter HS (Health Services Review) to identify services rendered by the physician (specialist). For Specialty Care Review, enter SC (Specialty Care Review) to indicate a referral request. UM02 Inpatient Certification Review: Type Code I Initial 1 AppealImmediate 2 AppealStandard For Inpatient Review: Initial Request: Update Request: Values Anthem Cannot Process: Use the following value: I Initial Use one of the following values: R 1 Appeal-Immediate—Use to request an emergency or urgent request for a re-review of a previously “Not Certified” request. This value is typically used when patient care is in progress. Do not use this value for elective services or services that have already been incurred. If the value equals R, we will reject the 278 Request.* 2 Appeal-Standard—Use to request a non-urgent re-review of a previously “Not Certified” request. This value is typically used when the services are elective or have already been incurred. 3 Cancel—Use to cancel (void) a previously submitted authorization. 4 Extension—Use to extend a previously submitted authorization. S Revised—Use to submit a change such as to the servicing provider(s) or the admission date. 3 Cancel 4 Extension S Revised (Renewal) * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-18 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level (Continued) (Continued) Health Services UM02 UM Review: Health Care Certification I Initial Type Code Services Review 1 AppealInformation Immediate 278 IG Page 141 2 AppealStandard For Outpatient Review: Initial Request: Update Request: Values Anthem Cannot Process: Use the following value: Use one of the following values: R (Renewal) 1 If the value equals R, we Appeal-Immediate—Use to will reject the 278 request an emergency or urgent request for a re-review Request.* of a previously “Not Certified” request. This value is typically used when patient care is in progress. Do not use this value for elective services or services that have already been incurred. 2 Appeal-Standard—Use to request a non-urgent re-review of a previously “Not Certified” request. This value is typically used when the services are elective or have already been incurred. 3 Cancel—Use to cancel (void) a previously submitted authorization. 4 Extension—Use to extend a previously submitted authorization. S Revised—Use to submit a change such as to the servicing provider(s) or the admission date. I Initial 3 Cancel 4 Extension S Revised Specialty For Specialty Care Review Care Review: Initial Update Request: I Initial Request: Values Anthem Cannot Process: 3 Cancel Use one of the following values: R (Renewal) 3 Cancel—Use to cancel (void) a previously submitted referral request. 1 (Appeal-Immediate) 4 Extension Use the following value: S Revised I Initial 4 Extension—Use to add additional visits to a previously certified referral request. 2 (Appeal-Standard) If the value equals R, 1, or 2, we will reject the 278 Request.* S Revised—Use to submit a change such as to the servicing provider(s) or date(s). * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-19 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level (Continued) UM03 UM Service Health Care Type Code Services Review Information 278 IG Page 141 Inpatient Review Service Type Codes Anthem Can Process: 1 2 48 69 70 99 A1 A2 A7 AB AI BB Medical Care Surgical Hospital-Inpatient Maternity Transplants Professional (Physician) VisitInpatient Professional (Physician) VisitNursing Home Professional (Physician) VisitSkilled Nursing Facility Psychiatric-Inpatient Rehabilitation-Inpatient Substance Abuse Partial Hospitalization Outpatient Review Service Type Codes Anthem Can Process: 1 2 4 5 6 7 8 12 14 15 16 17 18 20 21 23 24 25 26 27 28 33 34 35 36 37 38 39 40 Medical Care Surgical Diagnostic X-Ray Diagnostic Lab Radiation Therapy Anesthesia Surgical Assistant Durable Medical Equipment Purchase Renal Supplies in the Home Alternate Method Dialysis Chronic Renal Disease (CRD) Equipment Pre-Admission Testing Durable Medical Equipment Rental Second Surgical Opinion Third Surgical Opinion Diagnostic Dental Periodontics Restorative Endodontics Maxillofacial Prosthetics Adjunctive Dental Services Chiropractic Chiropractic Office Visits Dental Care Dental Crowns Dental Accident Orthodontics Prosthodontics Oral Surgery For Inpatient Review: If the value equals any code other than those listed in the Value column to the left, we will reject the 278 Request.* Send only one service type per transaction. Sending more than one indicates multiple events and the 278 Request will be rejected.* An example of an Inpatient Request follows: NM1*SJ*1*Duck*Donald****XX*1234567890~ N3 N4 PRV HL TRN UM*HS*I*99*B^21*****Y~ NM1*FA*2* Disney Hospital*****XX*1234567890~ N3 N4 PRV HL TRN UM*AR*I*48*B^21*****Y~ For Outpatient Review If the value equals any code other than those listed in the Value column to the left, we will reject the 278 Request.* We recommend using the most explicit service type. Examples of Outpatient Service Reviews follow: Services Performed by a Professional: NM1*1T*1*Duck*Donald*****XX*1234567890~ N3 N4 PRV HL TRN UM*HS*I*79*B^11*****Y~ Services Performed by a Facility: NM1*FA*2* Disney Hospital*****XX*1234567890~ N3 N4 PRV HL TRN UM*AR*I*62*B^22*****Y~ * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-20 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response ` (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level (Continued) (Continued) (Continued) Outpatient Review: UM UM03 Health Care Service Services Type Code Review Information 278 IG Page 141 42 44 45 46 50 51 52 53 54 56 57 58 59 61 62 63 64 65 67 68 69 70 71 72 73 74 75 76 77 78 79 80 82 83 84 85 93 94 95 98 A0 A1 A2 A3 A4 A6 A8 A9 AC AD AE AF AG AI IG Version 004010A1 (January 2009) (Continued) UM03 for Outpatient Review Home Health Care Home Health Visits Hospice Respite Care Hospital - Outpatient Hospital – Emergency Accident Hospital – Emergency Medical Hospital – Ambulatory Surgical Long Term Care Medically Related Transportation Air Transportation Cabulance Licensed Ambulance In-vitro Fertilization MRI/CAT Scan Donor Procedures Acupuncture Newborn Care Smoking Cessation Well Baby Care Maternity Transplants Audiology Exam Inhalation Therapy Diagnostic Medical Private Duty Nursing Prosthetic Device Dialysis Otological Exam Chemotherapy Allergy Testing Immunizations Family Planning Infertility Abortion AIDS Podiatry Podiatry-Office Visits Podiatry - Nursing Home Visits Professional (Physician) Visit-Office Professional (Physician) Visit Outpatient Professional (Physician) VisitNursing Home Professional (Physician) Visit-Skilled Nursing Facility Professional (Physician) Visit - Home Psychiatric Psychotherapy Psychiatric - Outpatient Rehabilitation Rehabilitation - Outpatient Occupational Therapy Physical Medicine Speech Therapy Skilled Nursing Care Substance Abuse Part II: 7-21 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level (Continued) (Continued) UM UM03 Health Care Services Review Information Service Type Code 278 IG Page 141 (Continued) UM03 for Outpatient Review (Continued) Outpatient Review Service Type Codes Anthem can process: AJ AK AL AR BC BD BE BF BG BS Alcoholism Drug Addiction Vision (Optometry) Experimental Drug Therapy Day Care (Psychiatric) Cognitive Therapy Massage Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Invasive Procedures Specialty Care Review: For Specialty Care Review 1 2 3 51 52 93 94 98 If the value equals any code other than those listed in the Value column to the left, we will reject the 278 Request.* Medical Care Surgical Consultation Hospital-Emergency Accident Hospital-Emergency Medical Podiatry Podiatry-Office Visits Professional (Physician) VisitOffice An example of an Specialty Care Review follows: NM1*1T*1*Duck*Donald*****XX*1234567890~ N3 N4 PRV HL TRN UM*SC*I*3*B^11*****Y~ Facility Type Code UM04-1 is required. If not included, we will reject the (Place of Service Code from Code 278 Request.* Source 237. See the 278 IG for information about the Code Source) If the Place of Service Code in UM04-1 does not correlate with UM03 (Type of Service Code), we will reject the 278 Request.* UM04-2 B UM04-1 Facility Code Qualifier UM05 Place of Service Code from Code Source 237 (See the 278 IG for information about the Code Source) See 278 IG UM05 is required if the admitting or principle diagnosis is accident related on the subscriber or dependent loop for all request types. See 278 IG Enter 03 (Emergency) or U (Urgent) only if the patient condition warrants a life endangerment situation and need for immediate treatment. Related Causes Information UM06 Level of Service Code UM04-2 is required. If not included, we will reject the 278 Request.* We cannot process 03 or U for Specialty Care Review. If UM06 is not included, we recognize the service as elective. If more than one provider loop is submitted as in the case for Inpatient Services, UM06 must have the same value in both loops. If the value for UM06 is different in multiple UM segments, we will reject the 278 Request.* * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-22 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes See 278 IG If 2000F, UM02 (Certification Type Code) equals 1, 2, 3, 4, or S (Updates) REF01 is required. See 278 IG If 2000F, UM02 (Certification Type Code) equals 1, 2, 3, 4, or S (Updates) REF02 is required. (Continued) Loop 2000F—Service Level REF REF01 Previous Certification Identification Reference Identification Qualifier 278 IG Page 150 REF02 Previous Certification Identifier DTP For Specialty Care Review, this segment is required. Service Date DTP03 278 IG Page 152 Proposed or Actual Service Date DTP For Admission Review, this segment is required. Admission Date DTP01 278 IG Page 154 See 278 IG See 278 IG If not sent for Admission Review, we will reject the 278 Request.* D8 We recommend using D8 (indicating one date) rather than RD8 (indicating a date range). If a date range is used, we assume the earliest date is the Admission Date. Date Time Qualifier DTP02 Date Time Period Format Qualifier DTP03 Date Expressed in Format CCYYMMDD See 278 IG Proposed or Actual Admission Date DTP If the date is not within twelve months of the current date, we will reject the 278 Request.* If the date is not within twelve (months of the current date, we will reject the 278 Request.* For Admission Review, this segment is recommended if known by requester. Discharge Date 278 IG Page 156 DTP Surgery Date For Admission Review, include this segment if the surgery date is different from the admission date, denoting the need for a preop day. For Specialty Care Review, this segment is not used. 278 IG Page 157 HI Procedures 278 IG Page 159 We recommend not using this segment for Specialty Care Review. We do not review procedures for referral requests. If procedures need a for coverage determination, then a Health Services Review needs to be requested in lieu of a Specialty Care Review. We highly recommend submitting procedures with procedure dates for all Outpatient Service Requests. If not sent, we may reject the 278 Request. We consider the first procedure code as primary and all others as secondary. Requests for surgical services, whether inpatient or outpatient, need to include procedures and procedure dates. HI01-1 BO Code List Qualifier Code BQ HI02 through HI12 Health Care Financing Administration Common Procedural Coding System International Classification of diseases Clinical Modification (ICD-9-CM) Procedures These data elements are for additional procedures. Use as appropriate. * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-23 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level HSD HSD01 Admission Review: Health Care Services Delivery Quantity Qualifier DY Days Outpatient Review: 278 IG Page 175 See 278 IG Specialty Care Review: VS Visits HSD02 Admission Review: Service Unit Count (Anticipated quantity of inpatient days) For Admission Review, if the value for HSD01 equals anything other than DY, we will reject the 278 Request.* For Health Services Review, any of the qualifiers may be used. For Specialty Care Review if the value for HSD01 equals anything other than VS, we will reject the 278 Request.* Specialty Care Review: (Anticipated quantity of visits) HSD03 – HSD08 CRC We do not use these data elements. For Admission Review, this segment is required if UM01 equals AR (Admission Review). Patient Condition Information 278 IG Page 180 CR1 This segment is used only for Health Services Review for an Ambulance Request. Ambulance Transport Information 278 IG Page 191 CR2 We do not use this segment. Spinal Manipulation Service Information 278 IG Page 194 CR5 We use this segment only for Health Services Review for Oxygen Services. Oxygen Therapy Information 278 IG Page 200 CR6 We use this segment only for Health Services Review for home health care. Home Health Care Information 278 IG Page 205 * For Reject Reason Codes, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-24 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Request This chart includes data elements requiring specific information for Anthem. Format all alpha characters as UPPERCASE. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level PWK Additional Service Information When documentation is necessary to support a 278 Request, identify the documentation using this segment. You should mail or fax the actual supporting documentation. Information about contracts and services that require authorizations is available at www.anthem.com. Once on the site, select "Providers," then "Virginia," then “Answers@Anthem,” then “Specialty Care/ Health Services.” 278 IG Addenda PWK01 See 278 IG Page 99 Attachment Report Type PWK02 Use the values indicated in the IG to identify the type of attachment. Codes used by Anthem Attachment Report include: Type Code AA Available on Request at Provider Site Email for supporting documentation is not available at this time. BM By Mail If you send supporting documentation by mail or facsimile, include a cover sheet listing the office contact name, phone number, fax number, policy number, patient name, date of service, provider number, and attachment control number. FX By Fax Illegible information will delay the 278 Response. VO Voice For Medical, Surgical, and Maternity Claims: Mailing Address: Anthem Blue Cross and Blue Shield Medical Management Mail Drop VA-44A P. O. Box 85638 Richmond, Va. 23286 Phone Number: (800) 242-7277 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2578 For Mental Health and Substance Abuse Services: MSG MSG01 Message Text Free-Form Message Text See 278 IG Mailing Address: Anthem Blue Cross and Blue Shield Behavioral Healthcare Mail Drop VA-43M 2221 Edward Holland Drive Richmond, Va. 23230 Phone Number: (800) 991-6095 Hours: 8 AM – 5 PM Eastern Time, Monday through Friday Fax Number: (804) 354-2536 or (800) 876-6310 If you send this segment, do not include characters used as delimiters. For example, if the pipe (|) is a subelement separator, do not use it in Free-Form Message text. 278 IG Page 211 IG Version 004010A1 (January 2009) Part II: 7-25 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.3 278 Response to Request for Review Payers send the ANSI ASC X12 278 Response in response to the 278 Request for Review. This section provides information for trading partners who receive the 278 Response from Anthem. We do not process 997 Functional Acknowledgments that trading partners submit to Anthem. The 278 Response includes the following levels: The Header contains transaction control information. The Detail contains information for the transaction’s business function and includes the following levels: − Loop 2000A—Utilization Management Organization (UMO) − Loop 2000B—Requester − Loop 2000C—Subscriber − Loop 2000D—Dependent − Loop 2000E—Service Provider − Loop 2000F—Service 7.3.1 278 Response Header The 276/277 IG explains the 278 Header. No specific information is required from Anthem. Please follow the instructions in the 278 IG. 7.3.2 278 Response Utilization Management (UMO) Level Loop 2000A Loop 2000A, Utilization Management Organization (UMO), identifies Anthem as the UMO. 7.3.3 Disclaimer For participating providers: IG Version 004010A1 (January 2009) No specific information is required from Anthem. Please follow the instructions in the 278 IG. Services subject to the FBPA (1999 Fair Business Practice Act – VA HB 2213) will be covered as long as the member’s Anthem coverage is active when the services are rendered, another payer is not responsible for payment of the claim and the information provided concerning the proposed treatment is accurate. Policy deductibles and co-payments always apply before final payment can be made, and prior services received by a member but not filed with the plan may affect our payment. Services not subject to FBPA are covered and paid based upon the terms of the member’s health care policy. Part II: 7-26 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.3.4 278 Response Requester Level Loop 2000B Loop 2000B, Requester Level, identifies who sent the 278 Request and should receive the response. 2000B AAA (Requester Address Validation) is the only segment in this loop that requires specific information for Anthem. All others are either not used by Anthem or contain the values from the corresponding 278 Request. 278 Loop 2000B—Requester Level 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Segment Data Element Value Definitions and Notes Loop 2010B—Requester Name NM1 NM108 Requester Name Identification Code Qualifier 278 IG Page 236 AAA Requester Address Validation 278 IG Page 241 IG Version 004010A1 (January 2009) NPI Compliant: XX National Provider Identifier (NPI) NPI Exempt: 24 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) NM109 NPI Compliant: (NPI) Requester Identifier NPI Exempt: If NM108 = 24: (Employer’s Identification Number) If NM108 = 34: (Social Security Number) If NM108 = 46: (Electronic Transmitter Identification Number) Most trading partners enter XX. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010B (Requester Name). To relate the error codes to specific segments and data elements, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. Part II: 7-27 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.3.5 278 Response Subscriber Level Loop 2000C Loop 2000C, Subscriber Level, identifies the subscriber, who may or may not be the patient. 2000C AAA (Requester Address Validation) and 2010CA AAA (Subscriber Request Validation) are the only segments in this loop that require specific information for Anthem. All others are either not used by Anthem or contain the values from the corresponding 278 Request. 278 Subscriber Level (2000C) 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Segment Definitions and Notes Loop 2000C—Subscriber Level AAA Requester Address Validation 278 IG Page 247 This AAA segment identifies reject reason codes for specific errors in the 278 Request, Loop 2000C (Subscriber Level). To relate the error codes to specific segments and data elements, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. Loop 2010CA—Subscriber Name AAA Subscriber Request Validation This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010CA (Subscriber Name). For error code information, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. 278 Addenda Page 134 IG Version 004010A1 (January 2009) Part II: 7-28 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.3.6 278 Response Dependent Level Loop 2000D Chapter 7B: 278 Health Care Services Request for Review and Response Loop 2000D, Dependent Level, is required on the 278 Request if the subscriber is not the patient. If you send this loop in the 278 Request, we will return it on the 278 Response. 2000D AAA (Dependent Request Validation) and 2010DA AAA (Subscriber Request Validation) are the only segments in this loop that require specific information for Anthem. All others are either not used by Anthem or contain the values from the corresponding 278 Request. Loop 2000D—Dependent Level 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Segment Definitions and Notes Loop 2000D—Dependent Level AAA Dependent Request Validation This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010D (Dependent Level). For error code information, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. 278 IG Page 273 Loop 2010DA—Dependent Name AAA Dependent Request Validation 278 Addenda Page 174 This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010DA (Dependent Level). For error code information, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. 7.3.7 278 Response Service Provider Level Loop 2000E Loop 2000E, Service Provider Level, identifies the service provider as sent on the 278 Request. The 278 Response will contain the same loops as sent on the 278 Request. The 2010E AAA (Service Provider Request Validation) is the only segment in this loop that requires specific information for Anthem. All others are either not used by Anthem or contain the values from the corresponding 278 Request. Loop 2000E—Service Provider Level 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Segment Data Element Value Definitions and Notes Loop 2010E—Service Provider Name NM1 Service Provider Name 278 IG Page 303 NM108 NPI Compliant: National Provider Identifier (NPI) Identification Code XX Qualifier NPI Exempt: 24 Employer’s Identification Number 34 Social Security Number 46 Electronic Transmitter Identification Number (ETIN) NM109 NPI Compliant: (NPI) Most trading partners enter XX. Examples of NPI exemptions include taxi services, home modifications, vehicle modifications, insect control, and respite services. Service Provider Identifier AAA Service Provider Request Validation 278 IG Page 314 NPI Exempt: If NM108 = 24: (Employer’s Identification Number) If NM108 = 34: (Social Security Number) If NM108 = 46: (Electronic Transmitter Identification Number) This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010E (Service Provider Level). For error code information, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. IG Version 004010A1 (January 2009) Part II: 7-29 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response 7.3.8 278 Response Service Level Loop 2000F Loop 2000F, Service Level, identifies the health care services requested. The following chart that follows explains the Service Level data elements that require specific information for Anthem. Loop 2000F—Service Level 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Loop 2000F—Service Level Segment Data Element AAA Service Request Validation This AAA segment identifies reject reason codes related to specific errors in the 278 Request, Loop 2010F (Service Level). 278 IG Page 323 For error code information, see the 278 Response AAA (Request Validation) Reject Reason Code Chart at the end of this Companion Document. HCR HCR01 Health Care Services Review Certification Action Code 278 IG Page 331 HCR03 Value Definitions and Notes Codes used by Anthem include: A1 Certified in total A3 Not Certified A6 Modified – Will represent Partial Certified/Partial Not Certified CT Contact Payer See 276 IG This data element is included if HCR01 equals A3 (Not Certified). Reject Reason Code DTP When applicable, the approved surgery date will display on the HI (Procedures) segment. Surgery Date For Specialty Care Review, this segment is not used by Anthem. 278 IG Page 341 HI HI01-1 Procedures Code List Qualifier Code Codes used by Anthem include: BO Health Care Financing Administration Common Procedural Coding System BQ International Classification of diseases Clinical Modification (ICD-9-CM) Procedures 278 IG Page 346 HI01-2 See 276 IG Procedure Code This data element includes the same value found on the 278 Request. For Specialty Care Review, if procedures are sent in on the 278 Request, HCR01 (Certification Action Code) equals CT (Contact Payer). HI01-3 See 276 IG Date Time Period Format Qualifier HI01-4 See 276 IG Date Time Period HI01-6 For Outpatient Review, these data elements indicate a date range to indicate the time period for certified, not certified, or modified. See 276 IG Procedure Quantity IG Version 004010A1 (January 2009) Part II: 7-30 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) Loop 2000F—Service Level 278 Response This chart includes only segments and data elements requiring specific information for Anthem. Segment Data Element Value Definitions and Notes (Continued) Loop 2000F—Service Level HSD HSD01 Admission Review: Health Care Services Quantity Qualifier Delivery DY Days Outpatient Review: For Outpatient Review: 278 IG Page 362 See 278 IG The value is based on the type of 278 Request. Specialty Care Review: VS Visits HSD02 Admission Review: Service Unit Count (Total inpatient days certified or not certified) Outpatient Review: (Total units certified or not certified) Specialty Care Review: (Quantity of total visits) IG Version 004010A1 (January 2009) Part II: 7-31 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II 7.4 Chapter 7B: 278 Health Care Services Request for Review and Response 278 Response AAA (Request Validation) Reject Reason Code Chart The 278 Response AAA (Request Validation) segments are in all 278 Response loops. When 278 Requests are rejected, these AAA segments provide reason codes. The following chart lists error descriptions and Reject Reason Codes for specific 278 Request segments and data elements. This chart is in the same sequential order as the 278 Request. 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Loop 2010B—Requester Name For Specialty Care Review, if NM101 equals FA (Facility), (Go to next column.) 41 (Authorization/Access Restrictions) If NM103 is not included, (Go to next column.) 44 (Invalid/Missing Provider Name) If NM101 equals 1P and NM104 is not included, (Go to next column.) 44 (Invalid/Missing Provider Name) If does not equal 24, (Go to next column.) 43 (Invalid/ Missing Provider Identification) For Specialty Care Review, if the Employer’s Identification Number in REF02 does not belong to the patient’s primary care physician, (Go to next column.) 49 (Provider is not Primary Care Physician) If N301 is not included, (Go to next column.) 97 (Invalid/Missing Provider Address) N401 If N401 is not included, Requester Requester City Name (Go to next column.) City/State/Zip N402 If N402 is not included, Code (Go to next column.) Requester State or Province Code 278 IG Page 66 97 (Invalid/Missing Provider Address) NM1 NM101 Requester Name Entity Identifier Code 278 IG Page 60 NM103 Requester Last or Organization Name NM104 Requester First Name NM108 Identification Code Qualifier REF REF02 Requester Supplemental Identification Requester Supplemental Identifier 278 IG Page 63 N3 N301 Requester Address Requester Address Line 278 IG Page 65 N4 IG Version 004010A1 (January 2009) Part II: 7-32 47 (Invalid/Missing Provider State) ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): (Continued) Loop 2010B—Requester Name PER PER02 Requester Contact Information Requester Contact Name 278 IG Page 68 Communication Number Qualifier PER03 PER04 Requester Contact Communication Number If PER02 is not included, (Go to next column.) 43 (Invalid/Missing Provider Identification) If PER03 is not included or includes less than 10 digits, (Go to next column.) 46 (Invalid/Missing Provider Phone Number) If PER04 is not included or includes less than 10 digits, (Go to next column.) 46 (Invalid/Missing Provider Phone Number) If this segment is not included, (Go to next column.) 15 (Required Application Data Missing) If NM109 is not included, (Go to next column.) 75 (Subscriber/Insured Not Found) If the patient is not eligible, (Go to next column.) 95 (Patient Not Eligible) If the value has less than nine characters, (Go to next column.) 72 (Invalid/Missing Subscriber/Insured ID) If the value has more than fourteen characters, (Go to next column.) 72 (Invalid/Missing Subscriber/Insured ID) If the diagnosis is related to an auto accident and this segment is not included, (Go to next column.) 15 (Required Application Data Missing) Loop 2000C—Subscriber Level DTP Accident Date 278 IG Page 75 Loop 2010CA—Subscriber Name NM1 NM109 Subscriber Name Subscriber Primary Identifier 278 IG Addenda Page 44 Loop 2000D—Dependent Level DTP DTP01 Accident Date Date/Time Qualifier 278 IG Page 98 DTP02 Date Time Period Format Qualifier DTP03 Accident Date HI Dependent Diagnosis 278 IG Page 103 If this segment is not included, Diagnosis Type Code (Go to next column.) HI01-1 15 (Required Application Data Missing) HI12-2 Diagnosis Code IG Version 004010A1 (January 2009) Part II: 7-33 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Loop 2010DA—Dependent Name NM1 NM103 Dependent Name Dependent Last Name 278 IG Addenda Page 138 NM104 Dependent First Name If the patient is not the subscriber and NM103 is not included, (Go to next column.) 15 (Required Application Data Missing) If the patient is not the subscriber and: NM104 is not included, (Go to next column.) 65 (Invalid/Missing Patient Name) The dependent is not found, (Go to next column.) 77 (Subscriber Found, Patient Not Found) There is more than one match, (Go to next column.) 77 (Subscriber Found, Patient Not Found) The dependent is not eligible, (Go to next column.) 95 (Patient Not Eligible) Loop 2000E—Service Provider Level All applicable segments and data elements For Admission Review, if the 278 Request includes more than one servicing facility and one servicing provider for a patient event, (Go to next column.) 04 (Authorized Quantity Exceeded) For Specialty Care Review, if the 278 Request includes more than one servicing provider for a patient event, (Go to next column.) All Segments and Data Elements within 2000E For Admission Review: 04 (Authorized Quantity Exceeded) We require two 2000E loops, one to identify the facility and one to identify the admitting physician. If more than one of each loop is submitted, (Go to next column.) We can accept only one servicing facility and one servicing provider for a patient event. If more than one of each is submitted, (Go to next column.) For Outpatient Review, if the 278 Request does not include a facility provider, we will accept only one servicing provider. If more than one is submitted, (Go to next column.) For Specialty Care Review, We can accept only one servicing provider for a patient event. If more than one of each is submitted, (Go to next column.) IG Version 004010A1 (January 2009) Part II: 7-34 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Loop 2010E—Service Provider Name NM1 NM101 Service Provider Name Entity Identifier Code For Admission Review, if there are not two occurrences of 2000E (Service Provider Level) as follows: 33 (Input Errors) One occurrence includes NM101 equaling 1T (Physician, Clinic, or Group Practice) or SJ (Service Provider) and 278 IG Page 124 One occurrence includes NM101 equaling FA (Facility). (Go to next column.) If NM103 is not included, (Go to next column.) Service Provider Last or Organization Name 15 (Required Application Data Missing) N3 N301 Service Provider Address Line If N301 is not included, (Go to next column.) 97 (Invalid/Missing Provider Address) Service Provider Address If N401 is not included, (Go to next column.) 97 (Invalid/Missing Provider Address) If N402 is not included, (Go to next column.) 47 (Invalid/Missing Provider State) 33 (Input Errors) NM103 278 IG Page 129 N4 N401 Service Provider City/State/Zip Code Service Provider City Name 278 IG Page 130 N402 Service Provider State or Province Code Loop 2000F—Service Level UM UM01 For Admission Review if either: Health Care Services Review Information Request Category Code AR (Admission Review) is not used to identify services by a facility, or 278 IG Page 141 HS (Health Services Review) is not used to identify services rendered by a physician (specialist), (Go to next column.) For Specialty Care Review, if 2010 (Requester Name) NM101 (Entity Identifier Code) equals FA (Facility), (Go to next column.) IG Version 004010A1 (January 2009) Part II: 7-35 41 (Authorization/Access Restrictions) ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Segment Data Element 278 Request Error Description (Continued) UM02 33 (Input Errors) UM Certification Type Code For Admission Review, if UM02 equals R (Renewal), (Go to next column.) For Specialty Care Review, if UM02 equals either: R (Renewal), 1 (Appeal-Immediate), or 2 (Appeal-Standard), (Go to next column.) 33 (Input Errors) For Admission Review: If UM03 equals a value other than one of the following: 1 Medical Care 2 Surgical 48 Hospital-Inpatient 69 Maternity 70 Transplants 99 Professional (Physician) Visit-Inpatient A1 Professional (Physician) Visit-Nursing Home A2 Professional (Physician) Visit-Skilled Nursing Facility A7 Psychiatric-Inpatient AB Rehabilitation-Inpatient AI Substance Abuse BB Partial Hospitalization 33 (Input Errors) Health Care Services Review Information 278 IG Page 141 UM03 Service Type Code (Go to next column.) If one UM03 (Service Type Code) is not included with either the Health Services Review transaction (UM01 equals HS) or the Admission Review transaction, (Go to next column.) IG Version 004010A1 (January 2009) For Admission Review if more than one service type is included in the transaction, (Go to next column.) 04 (Authorized Quantity Exceeded) For Outpatient Review: If UM03 equals a value other than one of the following: 1 Medical Care 2 Surgical 4 Diagnostic X-Ray 5 Diagnostic Lab 6 Radiation Therapy 7 Anesthesia 8 Surgical Assistant 12 Durable Medical Equipment Purchase 14 Renal Supplies in the Home 15 Alternate Method Dialysis 16 Chronic Renal Disease (CRD) Equipment 17 Pre-Admission Testing 33 (Input Errors) Part II: 7-36 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description (Continued) (Continued) (Continued) UM UM03 Health Care Services Review Information Service Type Code For Outpatient Review: If UM03 equals a value other than one of the following: 278 IG Page 141 18 20 21 23 24 25 26 27 28 33 34 35 36 37 38 39 40 42 44 45 46 50 51 52 53 54 56 57 58 59 61 62 63 64 65 67 68 69 70 71 72 73 74 75 76 77 78 79 80 82 83 84 IG Version 004010A1 (January 2009) then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): 33 (Input Errors) Durable Medical Equipment Rental Second Surgical Opinion Third Surgical Opinion Diagnostic Dental Periodontics Restorative Endodontics Maxillofacial Prosthetics Adjunctive Dental Services Chiropractic Chiropractic Office Visits Dental Care Dental Crowns Dental Accident Orthodontics Prosthodontics Oral Surgery Home Health Care Home Health Visits Hospice Respite Care Hospital - Outpatient Hospital – Emergency Accident Hospital – Emergency Medical Hospital – Ambulatory Surgical Long Term Care Medically Related Transportation Air Transportation Cabulance Licensed Ambulance In-vitro Fertilization MRI/CAT Scan Donor Procedures Acupuncture Newborn Care Smoking Cessation Well Baby Care Maternity Transplants Audiology Exam Inhalation Therapy Diagnostic Medical Private Duty Nursing Prosthetic Device Dialysis Otological Exam Chemotherapy Allergy Testing Immunizations Family Planning Infertility Abortion Part II: 7-37 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: Segment Data Element 278 Request Error Description (Continued) (Continued) (Continued) UM UM03 For Outpatient Review: Health Care Services Review Information Service Type Code If UM03 equals a value other than one of the following: 278 IG Page 141 85 93 94 95 98 A0 A1 A2 A3 A4 A6 A8 A9 AC AD AE AF AG AI A8 A9 AC AD AE AF AG AI AJ AK AL AR BC BD BE BF BG BS 33 (Input Errors) AIDS Podiatry Podiatry-Office Visits Podiatry - Nursing Home Visits Professional (Physician) VisitOffice Professional (Physician) Visit Outpatient Professional (Physician) VisitNursing Home Professional (Physician) VisitSkilled Nursing Facility Professional (Physician) Visit Home Psychiatric Psychotherapy Psychiatric - Outpatient Rehabilitation Rehabilitation - Outpatient Occupational Therapy Physical Medicine Speech Therapy Skilled Nursing Care Substance Abuse Psychiatric - Outpatient Rehabilitation Rehabilitation - Outpatient Occupational Therapy Physical Medicine Speech Therapy Skilled Nursing Care Substance Abuse Alcoholism Drug Addiction Vision (Optometry) Experimental Drug Therapy Day Care (Psychiatric) Cognitive Therapy Massage Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Invasive Procedures For Specialty Care Review: If UM03 equals a value other than one of the following: 1 2 3 51 52 93 94 98 IG Version 004010A1 (January 2009) then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): 33 (Input Errors) Medical Care Surgical Consultation Hospital-Emergency Accident Hospital-Emergency Medical Podiatry Podiatry-Office Visits Professional (Physician) VisitOffice Part II: 7-38 ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Segment Data Element 278 Request Error Description (Continued) UM04-1 If UM04-1 is not included, 15 (Required Application Data Missing) UM Facility Type Code If the Place of Service Code in UM04-1 does not correlate with UM03 (Type of Service Code), (Go to next column.) 33 (Input Errors) Health Care Services Review Information UM04-2 If UM04-1 is not included, (Go to next column.) 15 (Required Application Data Missing) 278 IG Page 141 Facility Code Qualifier UM05 Related Causes Information UM UM06 Health Care Services Review Information Level of Service Code If the admitting diagnosis is accident 15 (Required Application Data Missing) related and UM05 is not included, (Go to next column.) If the value for UM06 is different in multiple UM segments, (Go to next column.) 33 (Input Errors) 278 IG Page 141 REF Previous Certification Identification REF02 If 2000F (Service Level) UM02 Previous Certification (Certification Type Code) equals I (Initial) and this segment is Identifier included, and REF02 is included, (Go to next column.) 278 IG Page 150 If 2000F (Service Level) UM02 (Certification Type Code) equals 1, 2, 3, 4, or S (Updates) and either: T5 (Certification Information Missing) 33 (Input Errors) REF02 is not included, or Multiple copies of REF02 are sent, (Go to next column.) If 2000F (Service Level) UM02 (Certification Type Code) equals 3, 4, or S (Updates) and REF02 is not included, T5 (Certification Information Missing) (Go to next column.) DTP DTP03 Service Date Proposed or Actual Service Date If the date is not within twelve months of the current date, 62 (Date of Service Not Within Allowable Inquiry Period) (Go to next column.) 278 IG Page 152 DTP DTP01 Admission Date Date Time Qualifier If UM01 (Request Category Code) equals AR (Admission Review) and DTP01 is not sent, 278 IG Page 154 DTP03 DTP For Admission Review, or Outpatient Review, if a surgery date is included in this segment and surgical procedures (CPT code range 10021 - 69990 or ICD9 code range 00-86.99) are not sent in 2000F HI, (Go to next column.) 57 (Invalid/Missing Date[s] of Service) (Go to next column.) Surgery Date 278 IG Page 157 Proposed or Actual Admission Date IG Version 004010A1 (January 2009) If the date is not within twelve months of the current date, 62 (Date of Service Not Within Allowable Inquiry Period) (Go to next column.) Part II: 7-39 15 (Required Application Data Missing) ©Anthem Blue Cross and Blue Shield Anthem, Virginia Companion Guide Part II Chapter 7B: 278 Health Care Services Request for Review and Response (Continued) 278 Response AAA (Request Validation) Reject Reason Code Chart If the 278 Request Values are in Error as Follows: then, the 278 Response will reject the request, and the loop corresponding with the loop with the 278 Request error will include the following AAA03 (Reject Reason Code): Segment Data Element 278 Request Error Description HSD HSD01 Health Care Services Delivery Quantity Qualifier If UM01 (Request Category Code) 33 (Input Errors) equals AR (Admission Review) and HSD01 equals anything other than DY (Days), (Go to next column.) 278 IG Page 175 IG Version 004010A1 (January 2009) If UM01 (Request Category Code) equals SC (Specialty Care Review) and HSD01 equals anything other than VS (Visits), (Go to next column.) Part II: 7-40 ©Anthem Blue Cross and Blue Shield Anthem, Virginia
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