ADDENDUM 8--REFERRAL CERTIFICATION AND AUTHORITY
[Please label any written comments or e-mailed comments about this
section with the subject: Addendum 8]
The transaction selected for the referral certification and authority is
ASC X12N 278 - Health Care Services Review Information (004010X094).
A. Implementation Guide and Source
The source of the implementation guide for the referral certification
and authority is: Washington Publishing Company, 806 W. Diamond Ave.,
Suite 400, Gaithersburg, MD, 20878, Telephone 301- 590-9337, FAX:
301-869-9460. The website address is http://www.wpc-edi.com/hipaa/http://www.wpc-edi.com/hipaa/
B. Data Elements
- Action Code
- Admission Source Code
- Admission Type Code
- Agency Qualifier Code
- Ambulance Transport Code
- Ambulance Transport Reason Code
- Ambulance Trip Destination Address
- Ambulance Trip Origin Address
- Arterial Blood Gas Quantity
- Certification Condition Indicator
- Certification Expiration Date
- Certification Number
- Certification Type Code
- Chiropractic Series Treatment Number
- Citizenship Status Code
- Code Category
- Code List Qualifier Code
- Communication Number Qualifier
- Complication Indicator
- Condition Codes
- Contact Function Code
- Country Code
- Creation Date
- Current Health Condition Code
- Daily Oxygen Use Count
- Date Time Period Format Qualifier
- Date/Time Qualifier
- Delay Reason Code
- Dependent Additional Identification Text
- Dependent Additional Identifier
- Dependent Birth Date
- Dependent Citizenship Country Code
- Dependent First Name
- Dependent Gender Code
- Dependent Identification Code
- Dependent Last Name
- Dependent Marital Status Code
- Dependent Middle Name
- Dependent Name Prefix
- Dependent Name Suffix
- Dependent Trace Number
- Diagnosis Code
- Diagnosis Date
- Diagnosis Type Code
- Entity Identifier Code
- Entity Type Qualifier
- Equipment Reason Description
- Facility Code Qualifier
- Facility Type Code
- File Creation Time
- Follow-up Action Code
- Free-Form Message Text
- Full Destination Address
- Full Origin Address
- Hierarchical Child Code
- Hierarchical ID Number
- Hierarchical Level Code
- Hierarchical Parent ID Number
- Hierarchical Structure Code
- Home Health Certification Period
- Identification Code Qualifier
- Information Release Code
- Insured Indicator
- Last Admission Date
- Last Visit Date
- Level of Service Code
- Medicare Coverage Indicator
- Monthly Treatment Count
- Nature of Condition Code
- Nursing Home Residential Status Code
- Originator Application Transaction Identifier
- Oxygen Delivery System Code
- Oxygen Equipment Type Code
- Oxygen Flow Rate
- Oxygen Saturation Quantity
- Oxygen Test Condition Code
- Oxygen Test Findings Code
- Oxygen Use Period Hour Count
- Patient Condition Description Text
- Patient Discharge Facility Type Code
- Patient Status Code
- Patient Weight
- Period Count
- Physician Contact Date
- Physician Order Date
- Portable Oxygen System Flow Rate
- Previous Certification Identifier
- Procedure Date
- Procedure Monetary Amount
- Procedure Quantity
- Product/Service ID Qualifier
- Product/Service Procedure Code Text
- Product/Service Procedure Code
- Prognosis Code
- Proposed Admission Date
- Proposed Discharge Date
- Proposed Surgery Date
- Provider Code
- Provider Contact Name
- Provider Identifier
- Provider Service State Code
- Provider Specialty Certification Code
- Provider Specialty Code
- Quantity Qualifier
- Race or Ethnicity Code
- Reference Identification Qualifier
- Reject Reason Code
- Related-Causes Code
- Relationship To Insured Code
- Request Category Code
- Requester Address First Address Line
- Requester Address Second Address Line
- Requester City Name
- Requester Contact Communication Number
- Requester Contact Name
- Requester Country Code
- Requester First Name
- Requester Identifier
- Requester Last or Organization Name
- Requester Middle Name
- Requester Name Prefix
- Requester Name Suffix
- Requester Postal Code
- Requester State or Province Code
- Requester Supplemental Identifier
- Respiratory Therapist Order Text
- Round Trip Purpose Description Text
- Sample Selection Modulus
- Second Surgical Opinion Indicator
- Service Authorization Date
- Service From Date
- Service Provider City Name
- Service Provider Contact Communication Number
- Service Provider Country Code
- Service Provider First Address Line
- Service Provider First Name
- Service Provider Identifier
- Service Provider Last or Organization Name
- Service Provider Middle Name
- Service Provider Name Prefix
- Service Provider Name Suffix
- Service Provider Postal Code
- Service Provider Second Address Line
- Service Provider State or Province Code
- Service Provider Supplemental Identifier
- Service Trace Number
- Service Type Code
- Service Unit Count
- Ship/Delivery or Calendar Pattern Code
- State Code
- Stretcher Purpose Description Text
- Subluxation Level Code
- Subscriber Additional Identifier
- Subscriber Additional Information Text
- Subscriber Birth Date
- Subscriber Citizenship Country Code
- Subscriber First Name
- Subscriber Gender Code
- Subscriber Identifier
- Subscriber Last Name
- Subscriber Marital Status Code
- Subscriber Middle Name
- Subscriber Name Prefix
- Subscriber Name Suffix
- Subscriber Trace Number
- Surgery Date
- Surgical Procedure Code
- Time Period Qualifier
- Trace Type Code
- Transaction Segment Count
- Transaction Set Control Number
- Transaction Set Identifier Code
- Transaction Set Purpose Code
- Transaction Type Code
- Transport Distance
- Treatment Count
- Treatment Period Count
- Treatment Series Number
- Unit or Basis for Measurement Code
- Utilization Management Organization (UMO) or Last Name
- Utilization Management Organization (UMO) First Address Line
- Utilization Management Organization (UMO) First Name
- Utilization Management Organization (UMO) Middle Name
- Utilization Management Organization (UMO) Name Prefix
- Utilization Management Organization (UMO) Name Suffix
- Utilization Management Organization (UMO) Second Address Line
- Utilization Managment Organization (UMO) City Name
- Utilization Managment Organization (UMO) Contact Communication Number
- Utilization Managment Organization (UMO) Contact Name
- Utilization Managment Organization (UMO) Country Code
- Utilization Managment Organization (UMO) Identifier
- Utilization Managment Organization (UMO) Postal Code
- Utilization Managment Organization (UMO) State or Province Code
- Valid Request Indicator Code
- Version/Release/Industry Identifier
- X-Ray Availability Indicator Code
- 1861J1 Facility Indicator