Guarantor/Program Billing Defaults - 278 Authorization Request/Response Section - Cal-PM
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The 278 Authorization Request/Response Section is located on the Guarantor/Program Billing Defaults form once the correct Registry setting is enabled. With this section, you can set the default 278 billing file values. This information must be entered to process a 278 file.
Prerequisite:
ISA Segment Elements
| Field Name |
Input |
| Authorization Information Qualifier (ISA-01) |
Select the authorization information category/type. |
| Authorization Information (ISA-02) |
Enter the authorization information to include in the 278 file. |
| Security Information Qualifier (ISA-03) |
Select the type of security information requested. |
| Security Information (ISA-04) |
Enter the security information to include in the 278 file. |
| Interchange Sender ID Qualifier (ISA-05) |
Select the interchange sender ID category. |
| Interchange Sender ID (ISA-06) |
Select the interchange sender ID category. |
| Interchange Receiver ID Qualifier (ISA-07) |
Select the interchange sender ID category. |
| Interchange Receiver ID (ISA-08) |
Enter the receiver ID to include in the 278 file. |
| Repetition Separator (ISA-11) |
Enter the repetition separator. |
| Acknowledgement Requested (ISA-14) |
Mark if the acknowledgement will be requested from the interchange receiver. |
| Usage Indicator (ISA-15) |
Select the data usage. |
GS Segment Elements
| Field Name |
Input |
| Application Sender's Code (GS-02) |
Enter the sender's code. |
| Application Receiver's Code (GS-03) |
Enter the receiver's code. |
Utilization Management
| Field Name |
Input |
| Utilization Management Entity Type Code |
Select the type of utilization management. |
| Utilization Management Entity Type Qualifier |
Select whether or not the management entity is a person. |
| Utilization Management Organization Last Name or Organization Name |
Enter the organization name, or the surname, if a person. |
| Utilization Management Organization First Name |
Enter the given name, if a person. |
| Utilization Management Organization ID Code Qualifier |
Select the qualifier for the organization ID code. |
| Utilization Management Organization ID Code |
Enter the organization ID code. |
Requester Data
| Field Name |
Input |
| Requester Entity Type Code |
Select the type of requester. |
| Requester Entity Type Qualifier |
Select whether or not the requester entity is a person. |
| Requester Last or Organization Name |
Enter the organization name, or the surname, if a person. |
| Requester First Name |
Enter the given name, if a person. |
| Requester ID Code Qualifier |
Select the qualifier for the requester ID code. |
| Requester ID Code |
Enter the requester ID code. |
| Requester Supplemental ID Code Qualifier |
Select the qualifier for the requester's supplemental ID code. |
| Requester Supplemental ID |
Enter the requester's supplemental ID code. |
| Requester Address |
Enter the requester's address. |
| Requester ZIP Code |
Enter the requester's ZIP code. |
| Requester State |
Select the requester's state. |
| Requester City |
Enter the requester's city. |
