Health Care Services Review (278) - Overview

The 278 file is used as an electronic request, and response for member service authorizations.

If the request is successful a service authorization is created in myAvatar MSO.

• Default values for the 278 file must be defined in the Health Care Services Review (278) Defaults form in order to process 278 request files.
• The 278 request file must be compiled and loaded successfully in order to:
• The 2010A NM102, NM108 and NM109 segments in the 278 request file must match:
• The 2010B NM109 segment is mapped to the Submitter Identifier entry in the Contracting Provider Registration form.
• The 2010C REF01 segment qualifier must be ' IG' (Insurance Policy Number).
• The 2010E REF01 segment qualifier must be '1G' (Provider UPIN Number).
•  If the 2000F DTP01 segment qualifier is '472' (Service Date), the 2000F DTP03 segment date is used.
• If a single date is specified as the 2000F DTP02 qualifiers ('D8'), the date in the 2000F DTP03 segments will be used as the Begin Date of Authorization and End Date of Authorization.
• If a date range is specified as the 2000F DTP02 qualifiers ('RD8'), the date range in the 2000F DPT03 segments will be used as the Begin Date of Authorization and End Date of Authorization.
• The 2000F HI01 segment qualifiers must be 'BO' (Health Care Financing Administration Common Procedural Coding System).
• If the Enable Individual Service Begin/End Date registry setting is enabled the 2000F HI03 and HI04 segments are used to determine the Begin Date of Service and End Date of Service for each CPT Code specified in the 2000F HI02 segments.
• If the Enable Individual Service Begin/End Date registry setting is enabled but no individual service dates are entered in the 2000F HI03/HI04 segments of the 278 Request, the Begin Date of Service and End Date of Service for each service will be pulled from the 2000F DTP03 segment.
• If the Enable Individual Service Begin/End Date registry setting is disabled, individual service dates in the 2000F HI04 segments will be bypassed.
• If a single date is specified as the 2000F HI03 qualifiers ('D8'), the date in the 2000F HI04 segments will be used as the Begin Date of Service and End Date of Service.
• If a date range is specified as the 2000F HI03 qualifiers ('RD8'), the date range in the 2000F HI04 segments will be used as the Begin Date of Service and End Date of Service.
• The 2000F HI06 segments determines the units authorized for each CPT code in the service authorization.
• Service authorizations created through a 278 request file set Current Authorization Status to Pending, and Current Authorization Status Reason set to 278 Processing.