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
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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~
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