Sample Data for EDI 278 Request. Health Services Review

Health Care Claim Status Request and Response (278) transaction. Let's break down the components:


1. **ISA Segment:**

   - ISA: Interchange Control Header

   - 00: Authorization Information Qualifier

   - 00: Authorization Information

   - ZZ: Security Information Qualifier

   - 123456789ABC: Security Information

   - ZZ: Interchange ID Qualifier

   - FIDELIS: Interchange Sender ID

   - 180605: Interchange Date

   - 2320: Interchange Time

   - ^: Repetition Separator

   - 00501: Interchange Control Standards Identifier

   - 050443801: Interchange Control Version Number

   - 0: Interchange Control Number

   - T: Acknowledgment Requested


2. **GS Segment:**

   - GS: Functional Group Header

   - HI: Code identifying the type of functional group

   - 123456789ABC: Application Sender's Code

   - FIDELIS: Application Receiver's Code

   - 20180625: Date

   - 232054: Time

   - 50443801: Group Control Number

   - X: Responsible Agency Code

   - 005010X217: Version/Release/Industry Identifier Code


3. **ST Segment:**

   - ST: Transaction Set Header

   - 278: Transaction Set Identifier Code

   - 050443801: Transaction Set Control Number

   - 005010X217: Version/Release/Industry Identifier Code


4. **BHT Segment:**

   - BHT: Beginning of Hierarchical Transaction

   - 0007: Transaction Set Purpose Code

   - 13: Reference Identification

   - ABC123: Transaction Set Creation Date

   - 20180625: Transaction Set Creation Time

   - 152635: Transaction Set Reference Number


5. **HL Segment:**

   - HL: Hierarchical Level

   - 1: Hierarchical ID Number

   - 20: Hierarchical Level Code


6. **NM1 Segments:**

   - X3: Entity Identifier Code

   - FA: Entity Type Qualifier

   - IL: Entity Identifier Code

   - SJ: Entity Type Qualifier


7. **REF Segments:**

   - EI: Reference Identification Qualifier

   - 010200000: Reference Identification


8. **N3, N4 Segments:**

   - N3: Address Information

   - N4: Geographic Location


9. **DMG Segment:**

   - DMG: Demographic Information

   - D8: Date Time Period Format Qualifier

   - 20180101: Date of Birth


10. **TRN Segment:**

    - TRN: Trace

    - 1: Trace Type Code

    - A123456789: Trace Identifier

    - 9876543210: Originating Company Identifier


11. **UM Segment:**

    - UM: Health Claim Status

    - HS: Health Care Service Location Information

    - I: Claim Status Category Code

    - 2: Claim Status Code

    - 11:B: Entity Identifier Code


12. **REF Segment:**

    - BB: Reference Identification Qualifier

    - 123456789: Reference Identification


13. **DTP Segment:**

    - DTP: Date or Time Period

    - AAH: Date Time Period Format Qualifier

    - RD8: Date Time Period

    - 20180626-20180626: Date Range


14. **HI Segment:**

    - HI: Health Care Code Information

    - ABK:M1611: Code List Qualifier Code


15. **SV1 Segment:**

    - SV1: Professional Service

    - HC:J0897: Healthcare Service Information


16. **HSD Segment:**

    - HSD: Health Care Services Delivery


17. **SE Segment:**

    - SE: Transaction Set Trailer

    - 26: Number of Included Segments

    - 050443801: Transaction Set Control Number


18. **GE Segment:**

    - GE: Functional Group Trailer

    - 1: Number of Transaction Sets Included

    - 50443801: Group Control Number


19. **IEA Segment:**

    - IEA: Interchange Control Trailer

    - 1: Number of Included Functional Groups

    - 050443801: Interchange Control Number

--------

Health Services Review:

ISA*00* *00* *ZZ*123456789ABC *ZZ*FIDELIS

*180605*2320*^*00501*050443801*0*T*:~

GS*HI*123456789ABC*FIDELIS*20180625*232054*50443801*X*005010X217~

ST*278*050443801*005010X217~

BHT*0007*13*ABC123*20180625*152635~

HL*1**20*1~

NM1*X3*2*TRADING PARTNER*****PI*123456789~

HL*2*1*21*1~

NM1*FA*2*LAST*****XX*1114444440~

REF*EI*010200000~

N3*123 PARK WAY~

N4*NEWYORK*NY*11111~

HL*3*2*22*1~

NM1*IL*1*LASTNAME*FIRSTNAME****MI*100012121~

REF*6P*ABCD0001~

DMG*D8*20180101*M~

HL*4*3*EV*1~

TRN*1*A123456789*9876543210~

UM*HS*I*2*11:B**E***Y~

REF*BB*123456789~

DTP*AAH*RD8*20180626-20180626~

HI*ABK:M1611~

NM1*SJ*1*LASTNAME*FIRSTNAME****XX*1114444440~

N3*123 PARK WAY~

N4*NEWYORK*NY*11111~

HL*5*4*SS*0~

SV1*HC:J0897~

HSD*VS*1~

SE*26*050443801~

GE*1*50443801~

IEA*1*050443801~ 


Ref

https://www.fideliscare.org/Portals/0/Providers/Guides/2019-FidelisCare-CompanionGuide-278-English.pdf

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