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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

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