X12 HIPAA 278 Services Review

The EDI 278 transaction set is called Health Care Services Review Information. A healthcare provider, such as a hospital, will send a 278 transaction to request authorization from a payer, such as an insurance company. The hospital is asking the insurance company to review proposed healthcare services to be provided to a given patient, in order to obtain authorization for these services. The 278 transaction can be used to submit information in the following categories:

• Advance notification – for scheduled inpatient, specialty care or other services
• Completion notification – for patient arrival to or discharge from a facility
• Information copy – for any health services review information sent to service providers
• Change notification – for reporting changes to previously sent information

A 278 may relate to services to be administered by the healthcare service provider, or for referring an individual to another provider. The transaction may also be used by the payer to respond to this request for authorization. Thus, the 278 can be used either as a one-way transaction, or as a two-way “inquiry/response” type of transaction. Unlike other healthcare transactions that may be used in relation to multiple plan subscribers or patients, a single 278 is commonly used for one patient and one patient event.

The ANSI X12 EDI standards include three versions of the 278 transaction set. Of these, the Health Care Services Review and Response document was chosen by HIPAA as the standard format for EDI transmission of authorizations and referrals. This is an important issue of patient privacy, as 278 documents typically contain healthcare-related data, such as patient, diagnosis, or treatment information.

X12 HIPAA 278 Specification

X12 HIPAA 278 specification is available at:

• EdiNation

X12 HIPAA 278 Code Example

X12 HIPAA 278 code example is available at:

• EDI Tools for .NET X12 HIPAA 278 parse & generate C# example

X12 HIPAA 278 Sample File

ISA*00*          *00*          *ZZ*1234567        *ZZ*11111          *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X217~
ST*278*0001*005010X217~
BHT*0007*13*A12345*20050502*1101~
HL*1**20*1~
NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~
HL*2*1*21*1~
NM1*1P*1*GARDENER*JAMES****46*8189991234~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOE****MI*12345678901~
HL*4*3*EV*0~
TRN*1*111099*9012345678~
UM*SC*I*3*11:B*****Y~
HI*BF:41090:D8:20050430~
HSD*VS*1~
NM1*SJ*1*WATSON*SUSAN****34*987654321~
PER*IC**TE*4029993456~
SE*16*0001~
GE*1*101~
IEA*1*000000101~