Sample Data for EDI 278 Request. Admission Review

Example of an X12 EDI (Electronic Data Interchange) document. Each line represents a segment, and the segments are grouped to convey information about a specific transaction or business process. In this case, it seems to be a healthcare-related transaction, possibly related to a health insurance claim.


Here's a brief breakdown of the structure:


- ISA: Interchange Control Header

- GS: Functional Group Header

- ST: Transaction Set Header

- BHT: Beginning of Hierarchical Transaction

- HL: Hierarchical Level

- NM1: Name (such as organization or individual name)

- REF: Reference information

- N3: Address information

- N4: Location (city, state, zip)

- DMG: Demographic information

- TRN: Trace information

- UM: Unit of Measurement

- DTP: Date/Time Period

- HI: Healthcare Information Codes

- HSD: Health Care Services Delivery

- CL1: Institutional Claim Code

- SE: Transaction Set Trailer

- GE: Functional Group Trailer

- IEA: Interchange Control Trailer


These segments and their data provide details about the entities involved, their relationships, and the specifics of a healthcare-related transaction. Each segment has a specific purpose and follows a defined structure according to the X12 standards.

Detailed description:

Meaning of each subpart in the X12 EDI document:


1. ISA - Interchange Control Header:

   - 00: Authorization Information Qualifier

   - 00: Security Information Qualifier

   - ZZ: Sender ID Qualifier (e.g., mutual)

   - 123456789ABC: Sender Identification (sender's ID)

   - ZZ: Receiver ID Qualifier (e.g., mutual)

   - FIDELIS: Receiver Identification (receiver's ID)

   - 180805: Date (YYMMDD)

   - 1120: Time (HHMM)

   - ^: Data Element Separator

   - 00501: Interchange Control Standards Identifier

   - 050321011: Interchange Control Version Number

   - 0: Interchange Control Number

   - T: Acknowledgment Requested

   - ^: Field Separator


2. GS - Functional Group Header:

   - HI: Functional Identifier Code

   - 123456789ABC: Application Sender's Code

   - FIDELIS: Application Receiver's Code

   - 20180805: Date (YYMMDD)

   - 112054: Time (HHMMSS)

   - 12345678: Group Control Number

   - X: Responsible Agency Code

   - 005010X217: Version / Release / Industry Identifier Code


3. ST - Transaction Set Header:

   - 278: Transaction Set Identifier Code

   - 050443801: Transaction Set Control Number

   - 005010X217: Version / Release / Industry Identifier Code


4. BHT - Beginning of Hierarchical Transaction:

   - 0007: Hierarchical Structure Code

   - 13: Transaction Set Purpose Code

   - ABC123: Reference Identification

   - 20180625: Date (YYMMDD)

   - 152635: Time (HHMMSS)


5. HL - Hierarchical Level:

   - 1: Hierarchical ID Number

   - 20: Hierarchical Parent ID Number

   - 1: Hierarchical Level Code


6. NM1 - Name:

   - X3: Entity Identifier Code

   - 2: Entity Type Qualifier

   - TRADING PARTNER: Last Name or Organization Name

   - PI: Identification Code Qualifier

   - 123456789: Identification Code


7. HL - Hierarchical Level (2nd occurrence):

   - 2: Hierarchical ID Number

   - 1: Hierarchical Parent ID Number

   - 21: Hierarchical Level Code


8. NM1 - Name (2nd occurrence):

   - FA: Entity Identifier Code

   - 2: Entity Type Qualifier

   - LAST: Last Name

   - XX: Identification Code Qualifier

   - 1114444440: Identification Code


9. REF - Reference:

   - EI: Reference Identification Qualifier

   - 010200000: Reference Identification


10. N3 - Address Information:

    - 123 PARK WAY: Address Information


11. N4 - Location:

    - NEWYORK: City

    - NY: State

    - 11111: Postal Code


12. HL - Hierarchical Level (3rd occurrence):

    - 3: Hierarchical ID Number

    - 2: Hierarchical Parent ID Number

    - 22: Hierarchical Level Code


13. NM1 - Name (3rd occurrence):

    - IL: Entity Identifier Code

    - 1: Entity Type Qualifier

    - LASTNAME: Last Name

    - FIRSTNAME: First Name

    - MI: Identification Code Qualifier

    - 100012121: Identification Code


14. REF - Reference (2nd occurrence):

    - 6P: Reference Identification Qualifier

    - ABCD0001: Reference Identification


15. DMG - Demographic Information:

    - D8: Date Time Period Format Qualifier

    - 20180101: Date (YYYYMMDD)

    - M: Gender Code


16. HL - Hierarchical Level (4th occurrence):

    - 4: Hierarchical ID Number

    - 3: Hierarchical Parent ID Number

    - EV: Hierarchical Level Code

    - 0: Hierarchical Child Code


17. TRN - Trace Information:

    - 1: Trace Type Code

    - A123456789: Reference Identification

    - 9876543210: Originating Company Identifier


18. UM - Unit of Measurement:

    - AR: Unit or Basis for Measurement Code

    - I: Measurement Qualifier

    - 2: Measurement Value

    - 21:B: Composite Unit of Measure


19. REF - Reference (3rd occurrence):

    - BB: Reference Identification Qualifier

    - 123456789: Reference Identification


20. DTP - Date/Time Period (1st occurrence):

    - 435: Date/Time Qualifier

    - D8: Date Time Period Format Qualifier

    - 20180626: Date (YYYYMMDD)


21. DTP - Date/Time Period (2nd occurrence):

    - 096: Date/Time Qualifier

    - D8: Date Time Period Format Qualifier

    - 20180626: Date (YYYYMMDD)


22. HI - Healthcare Information Codes:

    - ABK:M1611: Healthcare Code Information


23. HSD - Health Care Services Delivery:

    - DY: Health Care Services Delivery Code

    - 1: Quantity


24. CL1 - Institutional Claim Code:

    - 3: Institutional Claim Type Code

    - 1: Institutional Claim Frequency Code


25. NM1 - Name (4th occurrence):

    - SJ: Entity Identifier Code

    - 1: Entity Type Qualifier

    - LAST: Last Name

    - FIRST: First Name

    - XX: Identification Code Qualifier

    - 1114444440: Identification Code


26. N3 - Address Information (2nd occurrence):

    - 123 PARK WAY: Address Information


27. N4 - Location (2nd occurrence):

    - NEWYORK: City

    - NY: State

    - 11111: Postal Code


28. SE - Transaction Set Trailer:

    - 26: Number of Segments in the Transaction Set

    - 050443801: Transaction Set Control Number


29. GE - Functional Group Trailer:

    - 1: Number of Transaction Sets Included

    - 12345678: Group Control Number


30. IEA - Interchange Control Trailer:

    - 1: Number of Functional Groups Included

    - 050321011: Interchange Control Number


--------

Sample Data for 278 Request. Admission Review:

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

*180805*1120*^*00501*050321011*0*T*^~

GS*HI*123456789ABC*FIDELIS*20180805*112054*12345678*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*0~

TRN*1*A123456789*9876543210~

UM*AR*I*2*21:B**E***Y~

REF*BB*123456789~

DTP*435*D8*20180626~

DTP*096*D8*20180626~

HI*ABK:M1611~

HSD*DY*1~

CL1*3*1~

NM1*SJ*1*LAST*FIRST****XX*1114444440~

N3*123 PARK WAY~

N4*NEWYORK*NY*11111~

SE*26*050443801~

GE*1*12345678~

IEA*1*050321011~

Ref

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

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