278 Health Care Services Review Request for Review and Response Companion Guide Specifications for Salt Lake County Public Sector Behavioral Health

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1 278 Health Care ervices eview equest for eview and esponse for alt Lake County Public ector Behavioral Health June 30, 2011 Prepared by: OptumHealth alt Lake County Page 1 of 55

2 1. Introduction This Companion Guide is intended to be used in conjunction with the National Electronic Data Interchange Transaction et Implementation Guide for Health Care ervices eview equest for eview and esponse for the version Combined May X096 and October X096A1 (this version combines the original 4010 and 4010A1 Addendum). The information contained in this Companion Guide are specific to authorizations for service for alt Lake County, Utah Medicaid and other locally funded Behavioral Health services for which OptumHealth alt Lake County has been contracted to manage. Utah Health Information Network (UHIN) will act as the clearinghouse for all transactions between facilities and providers to OptumHealth alt Lake County. Please contact UHIN at or call x200. UHIN will assign a Trading Partner Number (TPN) for EDI. 2. Purpose The purpose of this guide is to support the successful request for authorization of services and the response provided to the request via the 278 transactions. In provides the requirements for submission of requests and the data that will be provided in the response. PLEAE NOTE: The submission of all values required within this companion guide does not guarantee authorization. All authorizations are subject to alt Lake County and OptumHealth clinical guidelines, edits and audit processes. Page 2 of 55

3 3. General Guidelines 3.1. Information about the IA Interchange Control Header, G Function Group Header, GE Functional Group Trailer, and IEA Interchange Control Trailer can be found on the UHIN website Only Non-emergency and non-urgent outpatient authorizations requests should be sent via the 278. Emergency, urgent, and all authorization requests for levels of care above outpatient care should be telephoned into a Care Advocate to receive immediate attention. Please contact OptumHealth at Due to the complexity of authorization processing, requesters should send separate transactions sets 1 for different patients and events. There is no limit to the number of transaction sets that can be sent each day All submissions must use Trading Partner Number HT equests may be submitted 24 hours a day, 7 days a week A 997 Functional Acknowledgment will be available for pickup (download) within two hours of transmission for all 278 transactions. If you find no 997, contact UHIN In the 278 esponse, due to current limitations, rejections for data errors that would be reported at the AAA in Loops 2010B equester Name, 2000C ubscriber, 2010CA ubscriber Name, 2010E ervice Provider Name, 2000F ervice Level, will not be reported back to the equester via a 278. Instead, a report will be returned to the equester detailing these failed equests. (eport detail and delivery method TBD) 3.8. A 278 esponse will be available for all non-emergency, non-urgent, outpatient authorization requests within 3 business days of receipt of the request except those with data errors as stated in 3.7 above equests for reviews of previously submitted Authorization equests can be submitted via the 278. ee Loop 2000F, UM for details All syntactical error resolution and transmission level rejections will be handled by UHIN. Please contact UHIN. 1 A transaction set is comprised of s T Transaction et Header through E Transaction et Trailer. Page 3 of 55

4 4. Contact Information and upport hould you have additional questions regarding the use of this Companion Guide, please contact OptumHealth alt Lake County at Page 4 of 55

5 . 278 Authorization equest Page 5 of 55

6 Loop Page 6 of 55 T TANACTION ET HEADE Follow Implementation Guide for this and all data elements. BHT BEGINNING OF HIEACHICAL TANACTION Follow Implementation Guide for this and all data elements. BHT 01 Hierarchical tructure Code Follow Implementation Guide for this BHT 02 Transaction et Purpose Code Follow Implementation Guide for this BHT 03 ubmitter Transaction Identifier This data element will be used by the ubmitter to trace the transaction to OptumHealth LC and to reconcile the response to the BHT 04 Transaction et Creation Date Follow Implementation Guide for this BHT 05 Transaction et Creation Time Follow Implementation Guide for this BHT 06 Transaction Type Code Follow Implementation Guide for this 2000A UTILIZATION MANAGEMENT OGANIZATION LOOP 2000A HL UTILIZATION MANAGEMENT OGANIZATION Follow Implementation Guide for this and all data elements. 2000A HL 01 Hierarchical Number Follow Implementation Guide for this 2000A HL 03 Hierarchical Level Code Valid Value: 20 Information ource

7 Loop Page 7 of A HL 04 Hierarchical Child Code Valid Value: 1 Additional ubordinate HL s 2010A NM1 UTILIZATION MANAGEMENT OGANIZATION NAME LOOP 2010A NM1 UTILIZATION MANAGEMENT OGANIZATIONAL NAME Follow Implementation Guide for this and all data elements. 2010A NM1 01 Entity Identifier Code Valid Value: X3 Utilization Management Organization 2010A NM1 02 Entity Type Qualifier Valid Value: 2 Non-Person Entity 2010A NM1 03 Utilization Management OPTUMHEALTH LC P Organization Name 2010A NM1 04 First Name Not used 2010A NM1 05 Middle Name Not used 2010A NM1 08 Identification Code Qualifier Valid Value: 46 Electronic Transmitter Identification Number 2010A NM1 09 ubmitter Identifier HT B EQUETE LEVEL LOOP 2000B HL EQUETE HIEACHICAL LEVEL Follow Implementation Guide for this and all data elements. 2000B HL 01 Hierarchical Number Follow Implementation Guide for this 2000B HL 02 Hierarchical Parent Number Follow Implementation Guide for this

8 Loop Page 8 of B HL 03 Hierarchical Level Code Valid Value: 21 Information eceiver 2000B HL 04 Hierarchical Child Code Valid Value: 1 Additional ubordinate HL s 2010B EQUETE NAME LOOP 2010B NM1 EQUETE NAME 2010B NM1 01 Entity Identification Code Valid Values: 1P Provider FA Facility 2010B NM1 02 Entity Type Qualifier Valid Value: 1 Person 2 Non-Person Entity 2010B NM1 03 equester Last or Organization Name Follow Implementation Guide for this 2010B NM1 04 equester First Name Follow Implementation Guide for this 2010B NM1 05 equester Middle Name Follow Implementation Guide for this 2010B NM1 07 equester Name uffix Not used 2010B NM1 08 Information eceiver Identification Number Qualifier 2010B NM1 09 eceiver Primary Identifier NPI 2010B EF EQUETE UPPLEMENTAL ENTIFICATION Valid Value: XX NPI Please supply to ensure proper identification. This is equired for Out of Network Providers.

9 Loop Page 9 of B EF 01 eference Identification Qualifier Valid Values: EI Tax Y - N 2010B EF 02 eference upplemental Identifier Tax or N 2010B N3 EQUETE ADDE This segment equired for out of Network Providers. Follow Implementation Guide for this and all data elements. 2010B N4 EQUETE CITY/TATE/ZIP CODE 2010B PE EQUETE CONTACT INFOMATION This segment equired for out of Network Providers. Follow Implementation Guide for this and all data elements. This segment equired for out of Network Providers. Follow Implementation Guide for this and all data elements. 2010B PV EQUETE POVE Not used INFOMATION 2000C UBCIBE LEVEL LOOP For alt Lake County Public ector Behavioral Health, the subscriber is always the patient. Therefore, all patient data is included in this loop. 2000C HL UBCIBE LEVEL Follow Implementation Guide for this 2000C HL 01 Hierarchical Number Follow Implementation Guide for this

10 Loop Page 10 of C HL 02 Hierarchical Parent Number Follow Implementation Guide for this 2000C HL 03 Hierarchical Level Code Valid Value: 22 ubscriber 2000C HL 04 Hierarchical Child Code Valid Value: 1 Additional ubordinate HL s 2000C TN PATIENT EVENT TACKING NUMBE This TN segment is required if the subscriber is the patient and the requester needs to assign a unique trace number to the patient event request. This enables the requester to: uniquely identify this patient event request trace the request match the response to the request reference this request in any associated attachments containing additional patient information related to this patient event request. 2000C TN 01 Trace Type Code Valid Value: 1 Current Transaction Trace Numbers 2000C TN 02 Patient Event Tracking Number Follow Implementation Guide for this

11 Loop 2000C DTP LAT MENTUAL PEIOD Not used DATE 2000C DTP ETIMATED DATE OF BITH Not used 2000C DTP ONET OF CUENT Provide if known. YMPTOM O ILLNE DATE 2000C DTP 01 Date/Time Qualifier Valid Value: 431 Onset of Current ymptoms or Illness 2000C DTP 02 Date/Time Period Format Qualifier Valid Values: D8 CCYYMMDD D8 CCYYMMDD - CCYYMMDD 2000C DTP 03 Onset Date Follow Implementation Guide for this 2000C HI UBCIBE DIAGNOI equired for request to be processed. 2000C HI 01-1 Diagnosis Type Code Valid Values: BF Diagnosis Page 11 of C TN 03 Trace Assigning Entity Identifier Use this element to identify the organization that assigned this trace number. TN03 must be completed to aid requesters and clearinghouses in identifying their TN in the 278 response. Follow Implementation Guide for this 2000C TN 04 Trace Assigning Entity Additional Identifier 2000C DTP ACCENT DATE Not used Follow Implementation Guide for this

12 Loop Page 12 of 55 BJ Admitting Diagnosis BK Principal Diagnosis 2000C HI 01-2 Diagnosis Code Valid Value: DM-IV Code 2000C HI 01-3 Date/Time Period Format Qualifier Use only if known. Valid Value: D8 CCYYMMDD 2000C HI 01-4 Diagnosis Date Follow Implementation Guide for this 2000C HI 02-1 Diagnosis Type Code Use only if additional diagnoses known. Valid Values: BF Diagnosis BJ Admitting Diagnosis BK Principal Diagnosis 2000C HI 02-2 Diagnosis Code Valid Value: DM-IV Code 2000C HI 02-3 Date/Time Period Format Qualifier Use only if known. Valid Value: D8 CCYYMMDD 2000C HI 02-4 Diagnosis Date Follow Implementation Guide for this 2000C HI 03-1 Diagnosis Type Code Use only if additional diagnoses known. Valid Values: BF Diagnosis BJ Admitting Diagnosis BK Principal Diagnosis 2000C HI 03-2 Diagnosis Code Valid Value:

13 Loop Page 13 of 55 DM-IV Code 2000C HI 03-3 Date/Time Period Format Qualifier Use only if known. Valid Value: D8 CCYYMMDD 2000C HI 03-4 Diagnosis Date Follow Implementation Guide for this 2000C HI 04-1 Diagnosis Type Code Use only if additional diagnoses known. Valid Values: BF Diagnosis BJ Admitting Diagnosis BK Principal Diagnosis 2000C HI 04-2 Diagnosis Code Valid Value: DM-IV Code 2000C HI 04-3 Date/Time Period Format Qualifier Use only if known. Valid Value: D8 CCYYMMDD 2000C HI 04-4 Diagnosis Date Follow Implementation Guide for this 2000C HI 05-1 Diagnosis Type Code Use only if additional diagnoses known. Valid Values: BF Diagnosis BJ Admitting Diagnosis BK Principal Diagnosis 2000C HI 05-2 Diagnosis Code Valid Value: DM-IV Code 2000C HI 05-3 Date/Time Period Format Qualifier Use only if known. Valid Value:

14 Loop Page 14 of 55 D8 CCYYMMDD 2000C HI 05-4 Diagnosis Date Follow Implementation Guide for this 2000C HI 06-1 Diagnosis Type Code Not used 2000C HI 06-2 Diagnosis Code Not used 2000C HI 06-3 Date/Time Period Format Qualifier Not used 2000C HI 06-4 Diagnosis Date Not used 2000C HI 07-1 Diagnosis Type Code Not used 2000C HI 07-2 Diagnosis Code Not used 2000C HI 07-3 Date/Time Period Format Qualifier Not used 2000C HI 07-4 Diagnosis Date Not used 2000C HI 08-1 Diagnosis Type Code Not used 2000C HI 08-2 Diagnosis Code Not used 2000C HI 08-3 Date/Time Period Format Qualifier Not used 2000C HI 08-4 Diagnosis Date Not used 2000C HI 09-1 Diagnosis Type Code Not used 2000C HI 09-2 Diagnosis Code Not used 2000C HI 09-3 Date/Time Period Format Qualifier Not used 2000C HI 09-4 Diagnosis Date Not used 2000C HI 10-1 Diagnosis Type Code Not used 2000C HI 10-2 Diagnosis Code Not used 2000C HI 10-3 Date/Time Period Format Qualifier Not used 2000C HI 10-4 Diagnosis Date Not used

15 Loop Page 15 of C HI 11-1 Diagnosis Type Code Not used 2000C HI 11-2 Diagnosis Code Not used 2000C HI 11-3 Date/Time Period Format Qualifier Not used 2000C HI 11-4 Diagnosis Date Not used 2000C HI 12-1 Diagnosis Type Code Not used 2000C HI 12-2 Diagnosis Code Not used 2000C HI 12-3 Date/Time Period Format Qualifier Not used 2000C HI 12-4 Diagnosis Date Not used 2000C PWK ADDITIONAL PATIENT Not used INFOMATION 2010CA UBCIBE NAME LOOP 2010CA NM1 UBCIBE NAME 2010CA NM1 01 Entity Identifier Code Valid Value: IL Insured or ubscriber 2010CA NM1 02 Entity Type Qualifier Valid Value: 1 - Person 2010CA NM1 03 ubscriber Last Name Patient/Consumer Last Name 2010CA NM1 04 ubscriber First Name Patient/Consumer First Name 2010CA NM1 05 ubscriber Middle Name Patient/Consumer Middle Name 2010CA NM1 07 ubscriber Name uffix Not used 2010CA NM1 08 Identifier Code Qualifier Valid Value: MI Member Identification Number 2010CA NM1 09 ubscriber Primary Identifier PACMI for Medicaid; OptumHealth LC Member for Non-Medicaid 2010CA EF UBCIBE UPPLEMENTAL ENTIFICATION The equester may include any which may help in reconciling the

16 Loop response. 2010CA EF 01 eference Identification Qualifier Valid Values: EJ Patient Account Number HJ Identity Card Number NQ - Medicaid ecipient Identification Number Y ocial ecurity Number 2010CA EF 02 ubscriber upplemental Identifier equester Patient Number 2010CA DMG UBCIBE DEMOGAPHIC INFOMATION 2010CA DMG 01 Date/Time Period Format Qualifier Valid Value: D8 - CCYYMMDD 2010CA DMG 02 ubscriber Birth Date CCYYMMDD 2010CA DMG 03 ubscriber Gender Code Valid Values: F Female M Male U - Unknown 2000D DEPENDENT LEVEL LOOP DO NOT UE THI LOOP; The patient is always the subscriber for Medicaid and other LC funded Behavioral Health ervices. 2010DA NM1 DEPENDENT NAME LOOP DO NOT UE THI LOOP; The patient is always the subscriber for Medicaid and other LC funded Behavioral Health ervices. Page 16 of 55

17 Loop 2000E EVICE POVE LEVEL LOOP 2000E HL DETAIL EVICE POVE LEVEL Page 17 of 55 Follow Implementation Guide for this and all data elements. 2000E HL 01 Hierarchical Number Follow Implementation Guide for this 2000E HL 02 Hierarchical Parent Number Follow Implementation Guide for this 2000E HL 03 Hierarchical Level Code Valid Value: 19 Provider of ervices 2000E HL 04 Hierarchical Child Code Valid Value: 1 Additional ubordinate HL s 2000E MG MEAGE TEXT Not used 2010E EVICE POVE NAME 2010E NM1 EVICE POVE NAME This is required for any authorization to be accepted for processing. Only the first 2010E, NM1 will be used to process the request. 2010E NM1 01 Entity Identifier Code Valid Values: 1T Physician, Clinic or Group Practice FA Facility J ervice Provider 2010E NM1 02 Entity Type Qualifier Valid Value: 1 Person

18 Loop 2010E EF 02 ervice Provider upplemental Tax or N Identifier 2010E N3 EVICE POVE ADDE equired if needed to identify a specific location for a service provider that has multiple locations. Follow Implementation Guide for this and all data elements. Please complete with available information. 2010E N4 EVICE POVE equired if needed to identify a Page 18 of 55 2 Non-Person Entity Must be present for request to be processed. 2010E NM1 03 ervice Provider Last or Organization Name 2010E NM1 04 ervice Provider First Name Must be present if NM102 = 1 Person 2010E NM1 05 ervice Provider Middle Name Follow Implementation Guide for this 2010E NM1 07 ervice Provider Name uffix Not used 2010E NM1 08 Identification Code Qualifier Must be present. Valid Value: XX NPI 2010E NM1 09 ervice Provider Identifier NPI 2010E EF EVICE POVE ECONDAY ENTIFICATION 2010E EF 01 eference Identification Qualifier Valid Values: 24 Tax 34 N Please provide to ensure proper Provider identification

19 Loop CITY/TATE/ZIP CODE 2010E PE EVICE POVE CONTACT INFOMATION 2010E PV EVICE POVE This segment must be present. INFOMATION 2010E PV 01 Provider Code Valid Value: PE Performing 2010E PV 02 eference Identification Qualifier ZZ Provider Taxonomy Code 2010E PV 03 Provider Taxonomy Code Provider Taxonomy Code 2000F EVICE LEVEL LOOP 2000F HL EVICE LEVEL Follow Implementation Guide for this and all data elements. 2000F HL 01 Hierarchical Number Follow Implementation Guide for this 2000B HL 02 Hierarchical Parent Number Follow Implementation Guide for this 2000B HL 03 Hierarchical Level Code Valid Value: ervices Page 19 of 55 specific location for a service provider that has multiple locations. Follow Implementation Guide for this and all data elements. Please complete with available information. equesters are strongly urged to provide this information. Follow Implementation Guide for this and all data elements.

20 Loop Page 20 of B HL 04 Hierarchical Child Code Valid Value: 0 No ubordinate HL s 2000F TN EVICE TACE NUMBE equesters are strongly urged to provide this information assist them in reconciliation of the 278 response. Follow Implementation Guide for this and all data elements. 2000F TN 01 Trace Type Code Valid Value: 1 Current Transaction Trace Number 2000F TN 02 ervice Trace Number ervice Provider assigned ervice Trace Number 2000F TN 03 Trace Assigning Entity Use this element to identify the organization that assigned this trace number. TN03 must be completed to aid requesters and clearinghouses in identifying their TN in the 278 response. ervice Provider Trace Assigning Entity 2000F TN 04 Trace Assigning Entity Additional Identifier Follow Implementation Guide for this 2000F UM HEALTH CAE EVICE EVIEW INFOMATION 2000F UM 01 equest Category Code Valid Values: H Health ervices eview 2000F UM 02 Certification Type Code Valid Values: 2 Appeal tandard

21 Loop Page 21 of 55 3 Cancel (Previous equest) 4 Extension I Initial enewal - evised 2000F UM 03 ervice Type Code Valid Values: A4 Psychiatric A6 Psychotherapy A8 Psychiatric Outpatient 2000F UM 04-1 Facility Type Code Not used 2000F UM 04-2 Facility Code Not used 2000F UM 05-1 elated Causes Code Not used 2000F UM 05-2 elated Causes Code Not used 2000F UM 05-3 elated Causes Code Not used 2000F UM 05-4 tate Code Not used 2000F UM 05-5 Country Code Not used 2000F UM 06 Level of ervice Code Not used NOTE: If the ervice is Emergency or Urgent, the 278 should not be used. Call OptumHealth at for authorization of these services. 2000F UM 07 Current Health Condition Code Valid Values: 1 Acute 2 table 3 Chronic E Excellent

22 Loop Page 22 of 55 F Fair G Good P Poor 2000F UM 08 Prognosis Code Not used 2000F UM 09 elease of Information Code Valid Values: A Appropriate elease of Information on File I Informed Consent M Provider has Limited or estricted Ability to elease Data O On file at Payer or County Y Yes, Provider has a igned tatement Permitting elease of Medical Billing Data 2000F UM 10 Delay eason Code Not used 2000F EF PEVIOU CETIFICATION ENTIFICATION Follow Implementation Guide for this and all data elements. This should NOT be present when UM02 = I Initial equest. This is EQUIED when UM02 = 2, 3, 4,, or. 2000F EF 01 eference Identification Qualifier Valid Value: BB Authorization Number 2000F EF 02 Previous Authorization Number OptumHealth LC Authorization Number 2000F DTP EVICE DATE Follow Implementation Guide for this and all data elements

23 Loop H0039 JDOT Jail Diversion Outreach Team includes the following codes: OUTP General Outpatient ervices includes the following Page 23 of 55 in this segment. 2000F DTP ADMIION DATE Follow Implementation Guide for this and all data elements in this segment. 2000F DTP DICHAGE DATE Follow Implementation Guide for this and all data elements in this segment. 2000F DTP UGEY DATE Not used 2000F HI POCEDUE (EVICE) 2000F HI 01-1 Health Care Code Information Valid Value: ZZ Mutually defined (OptumHealth LC Level of Care Codes) BO Health Care Financing Administration Common Procedural Coding ystem (includes CPT codes) 2000F HI 01-2 Health Care Code OptumHealth LC Authorization Grouping Codes. Valid Values: (Where HI01-1 = ZZ) JCT Juvenile Corrections includes the following codes: 90802

24 Loop Page 24 of 55 codes: H0046 H2014 H2017 (Where HI01-1 = BO) HCPC/CPT Codes per Provider Contract 2000F HI 01-3 Date Time Period Format Qualifier Valid Values: D8 CCYYMMDD (single day) D8 CCYYMMDD-CCYYMMDD (Begin and End dates) 2000F HI 01-4 ervice Date Authorization equest Date(s) 2000F HI 01-5 ervice Amount Not used 2000F HI 01-6 ervice Quantity Enter the number of units requested. 2000F HI 01-7 Version Identifier Not used 2000F HI 02 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 03 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 04 HEALTH CODE INFOMATION ee explanation for composite above

25 Loop Page 25 of F HI 05 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 06 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 07 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 08 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 09 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 10 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 11 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 12 HEALTH CODE INFOMATION ee explanation for composite above 2000F HD HEALTH CAE EVICE DELIVE 2000F CC PATIENT CONDITION INFOMATION Not used The equester may include if they believe there are extenuating circumstances that support the Level of Care requested. 2000F CC 01 Condition Code Category Follow Implementation Guide for this 2000F CC 02 Certification Condition Indicator Follow Implementation Guide for this 2000F CC 03 Condition Code Follow Implementation Guide for this 2000F CC 04 Condition Code Follow Implementation Guide for this 2000F CC 05 Condition Code Follow Implementation Guide for this 2000F CC 06 Condition Code Follow Implementation Guide for this 2000F CC 07 Condition Code Follow Implementation Guide for this

26 Loop 2000F CL1 INTITUTIONAL CLAIM CODE Not used 2000F C1 AMBULANCE TANPOT INFOMATION 2000F NM1 EVICE LEVEL (CHIO) Not used 2000F C5 HOME OXYGEN THEAPY Not used INFOMATION 2000F C6 HOME HEALTH CAE Not used INFOMATION 2000F PWK ADDITIONAL EVICE INFOMATION Follow Implementation Guide for this and all data elements in this segment. Follow Implementation Guide for this and all data elements in this segment. 2000F MG MEAGE TEXT Not used E TANACTION ET TAILE Follow Implementation Guide for this and all data elements. Page 26 of 55

27 Page 27 of 55

28 278 Authorization esponse Page 28 of 55

29 Loop T TANACTION ET HEADE This follows the Implementation Guide for this Transaction. BHT BEGINNING OF HIEACHICAL TANACTION This follows the Implementation Guide for this Transaction. ee below for further information. BHT 01 Hierarchical tructure Code Valid Value: Information ource, Information eceiver, ubscriber, Dependent, Provider of ervice, ervices BHT 02 Transaction et Purpose Code Valid Value: 11 - esponse BHT 03 ubmitter Transaction Identifier This is the ubmitter Transaction Identifier sent by the ubmitter in the (ee BHT03 in the equest portion of this guide). BHT 04 Transaction et Creation Date This will be the Date that OptumHealth LC created the esponse. BHT 05 Transaction et Creation Time This will be the Time that OptumHealth LC created the esponse. BHT 06 Transaction Type Code Valid Value: 18 esponse No Further Updates to Follow 19 esponse Further Updates to Follow Page 29 of 55

30 Loop 2000A UTILIZATION MANAGEMENT OGANIZATION LOOP 2000A HL UTILIZATION MANAGEMENT OGANIZATION 2000A AAA UTILIZATION MANAGEMENT OGANIZATION LEVEL Page 30 of 55 AT Administrative Action This follows the Implementation Guide for this Transaction. This segment is required when the ubmitted transaction is rejected by UHIN. Contact UHIN to resolve these issues. 2000A AAA 01 Valid equest Indicator Valid Values: N No; the request or a data element in the request is NOT VAL. Please see the reason for rejection in AAA03 of this segment. Y Yes; the request was valid, however the transaction has been rejected for some other reason. Please see the reason for rejection in AAA03 of this segment. 2000A AAA 03 eject eason Code Valid Values: 04 Authorized Quantity Exceeded (More transactions than agreed to between ubmitter and UHIN) 41 Access estrictions (No Trading Partner Agreement) 42 Unable to espond at Current Time 79 Invalid Participant Identification

31 Loop Page 31 of A AAA 04 Follow Up Action Code Valid Values: C Please Correct and esubmit N esubmission Non Allowed P Please esubmit Original Transaction 2010A NM1 UTILIZATION MANAGEMENT OGANIZATION NAME LOOP 2010A NM1 ECIEVE INDIVUAL O OGANIZATIONAL NAME 2010A NM1 01 Entity Identification Code This follows the Implementation Guide for this 2010A NM1 02 Entity Type Qualifier Valid Value = 2 Non-Person Entity 2010A NM1 03 Utilization Management OptumHealth LC P Organization Name 2010A NM1 04 Utilization Management First Name Not used 2010A NM1 05 Utilization Management Middle Not used Name 2010A NM1 07 Utilization Management uffix Not used 2010A NM1 08 Information eceiver Identification Number Qualifier 2010A NM1 09 eceiver Primary Identifier NEED OU TAX 2010A PE UTILIZATION MANAGEMENT OGANIZATION CONTACT INFOMATION Valid Value = 24 Tax Identification Number for OptumHealth LC 2010A PE 01 Contact Function Code This follows the Implementation Guide for this 2010A PE 02 Utilization Management Organization Contact Name OptumHealth LC

32 Loop Page 32 of A PE 03 Communication Number Qualifier Valid Values: EM FX Fax TE Telephone A PE 04 Utilization Management Organization Contact Number 2010A PE 05 Communication Number Qualifier Valid Values: EM FX Fax TE Telephone Contact Number 2010A PE 06 Utilization Management Organization Contact Number 2010A PE 07 Communication Number Qualifier Valid Values: EM FX Fax TE Telephone Contact Number 2010A PE 08 Utilization Management Organization Contact Number 2010A AAA UTILIZATION MANAGEMENT This will contain OGANIZATION EQUET information about why a request VALATION was rejected at this level. 2010A AAA 01 Valid equest Indicator Valid Values: N No; the request failed due to data issues e.g. information needed to process the request not present or not valid Y Yes; the request is valid, but failed due to some other processing issue

33 Loop Page 33 of A AAA 03 eject eason Code 41 Authorization/Access estrictions; this indicates that the requester is not allowed to send or received authorizations via the 278 process 42 Unable to espond at Current Time; this indicates a problem with OptumHealth LC Authorization ystem; contact OptumHealth 79 Invalid Participant Identification; this indicates that that the code used in 2010A of the original request is invalid 80 No esponse eceived; indicates that OptumHealth LC Authorization ystem has not received a response for additional information in the expected timeframe and has terminated the request T4 Payer Name or Identifier Missing; indicates that the Identifier(s) for OptumHealth identified in Loop 2010A is missing. 2010A AAA 04 Follow-up Action Code Valid Values: N esubmission Not Allowed P Please esubmit Original Transaction Y Do Not esubmit; We will hold

34 Loop 2000B EQUETE LEVEL LOOP 2000B HL EQUETE HIEACHICAL LEVEL Page 34 of 55 your request and respond again shortly This follows the Implementation Guide for this Transaction. 2010B EQUETE NAME LOOP 2010B NM1 EQUETE NAME The receiver is the facility/provider who is receiving the authorization decision. 2010B NM1 01 Entity Identification Code This follows the Implementation Guide for this 2010B NM1 02 Entity Type Qualifier This follows the Implementation Guide for this 2010B NM1 03 equester Last or Organization Name This follows the Implementation Guide for this 2010B NM1 04 equester First Name This follows the Implementation Guide for this 2010B NM1 05 equester Middle Name This follows the Implementation Guide for this 2010B NM1 07 equester Name uffix Not used 2010B NM1 08 Information eceiver Identification Number Qualifier Valid Values: 24 - Tax Identification Number 34 ocial ecurity Number 2010B NM1 09 eceiver Primary Identifier equester s Tax or N 2010B EF EQUETE UPPLEMENTAL ENTIFICATION 2010B EF 01 eference Identification Qualifier Valid Value: equired for request to be processed.

35 Loop Page 35 of 55 ZH OptumHealth Provider 2010B EF 02 eference upplemental Identifier OptumHealth Provider 2010B AAA EQUETE EQUET VALATION This will contain information about why a request was rejected at this level. 2010B AAA 01 Valid equest Indicator Valid Values: N No; the request failed due to data issues e.g. information needed to process the request not present or not valid Y Yes; the request is valid, but failed due to some other processing issue 2010B AAA 03 eject eason Code 41 Authorization/Access estrictions; this indicates that the requester is not allowed to send or received authorizations via the 278 process 43 Invalid/Missing Provider Identification 44 Invalid/Missing Provider Name 45 Invalid/Missing Provider pecialty 50 Provider Ineligible for Inquiries/not authorized for requests 79 Invalid Participant Identification; supplemental Facility/Provider s (OptumHealth Provider ) invalid/missing

36 Loop Page 36 of B AAA 04 Follow-up Action Code Valid Values: C Please Correct and esubmit N esubmission Not Allowed esubmission Allowed 2010B PV EQUETE POVE INFOMATION This segment will contain the information submitted in the original request 2010B. 2000C UBCIBE LEVEL LOOP For alt Lake County Public ector Behavioral Health, the subscriber is always the patient. Therefore, all patient data is included in this loop. 2000C HL UBCIBE LEVEL This follows the Implementation Guide for this Transaction. 2000C TN PATIENT EVENT TACKING NUMBE This will return the data supplied in the original request to assist the equester in reconciling their authorization requests. 2000C TN 01 Trace Type Code Valid Value: 2 eferenced (original request) Transaction Trace Number. 2000C TN 02 Patient Event Tracking Number This will be the Tracking Number sent in the 2000C TN 03 Trace Assigning Entity Identifier This will be the value sent in the 2000C TN 04 Trace Assigning Entity Additional This will be the value sent in the Identifier original request, if supplied. 2000C TN PATIENT EVENT TACKING This will contain tracking

37 Loop NUMBE Page 37 of 55 information for the request as assigned by OptumHealth LC. 2000C TN 01 Trace Type Code Valid Value: 1 Current Transaction Trace Number (as assigned by OptumHealth LC). 2000C TN 02 Patient Event Tracking Number This will be the Tracking Number assigned by OptumHealth LC. 2000C TN 03 Trace Assigning Entity Identifier This will be the value assigned by OptumHealth LC. 2000C TN 04 Trace Assigning Entity Additional Identifier 2000C AAA UBCIBE EQUET VALATION Not used. This will contain information about why a request was rejected at this level. 2000C AAA 01 Valid equest Indicator Valid Values: N No; the request failed due to data issues e.g. information needed to process the request not present or not valid Y Yes; the request is valid, but failed due to some other processing issue 2000C AAA 03 eject eason Code Valid Values: 15 Missing Diagnosis and/or Diagnosis Dates 33 Invalid Diagnosis and/or Diagnosis Dates 56 Inappropriate Date(s)

38 Loop Page 38 of C AAA 04 Follow-up Action Code Valid Values: C Please Correct and esubmit N esubmission Not Allowed 2000C DTP ACCENT DATE Not used 2000C DTP LAT MENTUAL PEIOD Not used DATE 2000C DTP ETIMATED DATE OF BITH Not used 2000C DTP ONET OF CUENT YMPTOM O ILLNE DATE This will return the data supplied in the 2000C DTP 01 Date/Time Qualifier This will be the data supplied in the 2000C DTP 02 Date/Time Period Format Qualifier This will be the data supplied in the 2000C DTP 03 Onset Date This will be the data supplied in the 2000C HI UBCIBE DIAGNOI ee below for explanation of data 2000C HI 01-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 01-2 Diagnosis Code This will be the data supplied in the 2000C HI 01-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 01-4 Diagnosis Date This will be the data supplied in the 2000C HI 02-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 02-2 Diagnosis Code This will be the data supplied in the

39 Loop Page 39 of C HI 02-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 02-4 Diagnosis Date This will be the data supplied in the 2000C HI 03-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 03-2 Diagnosis Code This will be the data supplied in the 2000C HI 03-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 03-4 Diagnosis Date This will be the data supplied in the 2000C HI 04-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 04-2 Diagnosis Code This will be the data supplied in the 2000C HI 04-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 04-4 Diagnosis Date This will be the data supplied in the 2000C HI 05-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 05-2 Diagnosis Code This will be the data supplied in the 2000C HI 05-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 05-4 Diagnosis Date This will be the data supplied in the

40 Loop Page 40 of C HI 06-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 06-2 Diagnosis Code This will be the data supplied in the 2000C HI 06-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 06-4 Diagnosis Date This will be the data supplied in the 2000C HI 07-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 07-2 Diagnosis Code This will be the data supplied in the 2000C HI 07-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 07-4 Diagnosis Date This will be the data supplied in the 2000C HI 08-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 08-2 Diagnosis Code This will be the data supplied in the 2000C HI 08-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 08-4 Diagnosis Date This will be the data supplied in the 2000C HI 09-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 09-2 Diagnosis Code This will be the data supplied in the

41 Loop Page 41 of C HI 09-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 09-4 Diagnosis Date This will be the data supplied in the 2000C HI 10-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 10-2 Diagnosis Code This will be the data supplied in the 2000C HI 10-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 10-4 Diagnosis Date This will be the data supplied in the 2000C HI 11-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 11-2 Diagnosis Code This will be the data supplied in the 2000C HI 11-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 11-4 Diagnosis Date This will be the data supplied in the 2000C HI 12-1 Diagnosis Type Code This will be the data supplied in the 2000C HI 12-2 Diagnosis Code This will be the data supplied in the 2000C HI 12-3 Date/Time Period Format Qualifier This will be the data supplied in the 2000C HI 12-4 Diagnosis Date This will be the data supplied in the

42 Loop Page 42 of C PWK ADDITIONAL PATIENT INFOMATION Not used 2010CA UBCIBE NAME LOOP 2010CA NM1 UBCIBE NAME 2010CA NM1 01 Entity Identifier Code Valid Value: IL ubscriber/member 2010CA NM1 02 Entity Type Qualifier Valid Value: 1 Person 2010CA NM1 03 ubscriber Last Name This will either be the Consumer Last Name that OptumHealth LC has for the requested OptumHealth Consumer O The name that was supplied on the original request (when Loop 2000C, AAA is returned in the response) 2010CA NM1 04 ubscriber First Name This will either be the Consumer First Name that OptumHealth LC has for the requested OptumHealth Consumer O The name that was supplied on the original request (when Loop 2000C, AAA is returned in the response) 2010CA NM1 05 ubscriber Middle Name This will either be the Consumer Middle Name that OptumHealth LC has for the requested OptumHealth

43 Loop Page 43 of 55 Consumer O The name that was supplied on the original request (when Loop 2000C, AAA is returned in the response) 2010CA NM1 07 ubscriber Name uffix Not used 2010CA NM1 08 Identifier Code Qualifier Valid Value: MI Member Identification Number (OptumHealth Consumer ) 2010CA NM1 09 ubscriber Primary Identifier OptumHealth Consumer or UNKNOWN 2010CA EF UBCIBE UPPLEMENTAL ENTIFICATION equired when the patient has Medicaid coverage 2010CA EF 01 eference Identification Qualifier Valid Value: NQ Medicaid ecipient Identification Number 2010CA EF 02 ubscriber upplemental Identifier Medicaid Number 2010CA DMG UBCIBE DEMOGAPHIC INFOMATION 2010CA DMG 01 Date/Time Period Format Qualifier Valid Value: D8 - CCYYMMDD 2010CA DMG 02 ubscriber Birth Date CCYYMMDD 2010CA DMG 03 ubscriber Gender Code Valid Values: F Female M Male U - Unknown 2010CA EF UBCIBE UPPLEMENTAL ENTIFICATION This will contain data as supplied by the equester in the

44 Loop Page 44 of CA EF 01 eference Identification Qualifier This will be the data supplied in the 2010CA EF 02 ubscriber upplemental Identifier This will be the data supplied in the 2000D DEPENDENT LEVEL LOOP THI LOOP NOT UED; The patient is always the subscriber for Medicaid and other LC funded Behavioral Health ervices. 2010DA NM1 DEPENDENT NAME LOOP THI LOOP NOT UED; The patient is always the subscriber for Medicaid and other LC funded Behavioral Health ervices. 2000E EVICE POVE LEVEL LOOP 2000E HL DETAIL EVICE POVE LEVEL This follows the Implementation Guide for this Transaction. 2000E MG MEAGE TEXT This follows the Implementation Guide for this Transaction. 2000E NM1 EVICE POVE NAME 2000E NM1 01 Entity Identifier Code This follows the Implementation Guide for this 2000E NM1 02 Entity Type Qualifier This follows the Implementation Guide for this 2000E NM1 03 ervice Provider Last or Organization Name This will be the ervice Provider Las or Organization Name contained on OptumHealth LC Authorization

45 Loop 2010E EF EVICE POVE Not used ECONDAY ENTIFICATION 2010E EF 01 eference Identification Qualifier Valid Value: ZH OptumHealth Provider 2010E EF 02 ervice Provider upplemental OptumHealth Provider Identifier 2010E N3 EVICE POVE ADDE This segment will contain the ervice Provider Address as contained in OptumHealth LC Authorization ystem and as authorized/denied for service. 2010E N3 01 ervice Provider Address Line OptumHealth ervice Provider Address Line 1 Page 45 of 55 ystem. 2000E NM1 04 ervice Provider First Name This will be the ervice Provider Last or Organization Name contained on OptumHealth LC Authorization ystem. 2000E NM1 05 ervice Provider Middle Name This will be the ervice Provider First contained on OptumHealth LC Authorization ystem. 2000E NM1 07 ervice Provider Name uffix Not used 2000E NM1 08 Identification Code Qualifier Valid Values: 24 Tax Identification Number 34 ocial ecurity Number 2000E NM1 09 ervice Provider Identifier Tax or N 2010E EVICE POVE UPPLEMENTAL ENTIFICATION

46 Loop Page 46 of E N3 02 ervice Provider Address Line OptumHealth ervice Provider Address Line E N4 EVICE POVE CITY/TATE/ZIP CODE This segment will contain the ervice Provider Address as contained in OptumHealth LC Authorization ystem and as authorized/denied for service. 2010E N4 01 ervice Provider City Name OptumHealth ervice Provider City 2010E N4 02 ervice Provider tate OptumHealth ervice tate 2010E N4 ervice Provider ZIP Code OptumHealth ervice Provider ZIP Code 2010E N4 ervice Provider County Code OptumHealth ervice Provider Country Code 2010E PE EVICE POVE CONTACT INFOMATION 2010E AAA EVICE POVE EQUET VALATION Not used This will contain information about why a request was rejected at this level. 2000E AAA 01 Valid equest Indicator Valid Values: N No; the request failed due to data issues e.g. information needed to process the request not present or not valid Y Yes; the request is valid, but failed due to some other processing issue 2000E AAA 03 eject eason Code Valid Values: 15 Missing Diagnosis and/or Diagnosis Dates

47 Loop Page 47 of Input Errors 41 Authorization/Access estrictions 43 Invalid/Missing Provider Identification 44 Invalid/Missing Provider Name 45 Invalid/Missing Provider pecialty 47 Invalid/Missing Provider tate 51 Provider Not on File 52 ervice Dates Not Within Provider Plan Enrollment 79 Invalid/Missing upplemental 2000E AAA 04 Follow-up Action Code Valid Values: C Please Correct and esubmit N esubmission Not Allowed 2010E PV EVICE POVE INFOMATION When the request is approved, this will indicate the ervice Provider ole. 2010E PV 01 Provider Code Valid Value: PE Performing 2010E PV 02 eference Identification Qualifier Valid Value: ZZ Provider Taxonomy Code 2010E PV 03 Provider Taxonomy Code Provider Taxonomy Code 2000F EVICE LEVEL LOOP 2000F HL EVICE LEVEL This follows the Implementation Guide for this Transaction.

48 Loop Page 48 of F TN EVICE TACE NUMBE If this was supplied in the original request this will return the submitted data. 2000F TN EVICE TACE NUMBE If this was supplied in the original request this will return the submitted data. 2010F AAA EVICE EQUET VALATION This will contain information about why a request was rejected at this level. PLEAE NOTE: If an adverse benefit determination has been made, the reason for that determination will be reflected in the HC segment of this Loop. 2000F AAA 01 Valid equest Indicator Valid Values: N No; the request failed due to data issues e.g. information needed to process the request not present or not valid Y Yes; the request is valid, but failed due to some other processing issue 2000F AAA 03 eject eason Code Valid Values: 15 Missing Diagnosis and/or Diagnosis Dates 33 Input Errors 52 ervice Dates Not Within Provider Plan Enrollment 57 Invalid/Missing Date(s) of

49 Loop Page 49 of 55 ervice 60 Date of Birth after requested Date(s) of ervice 61 Date of Death precedes requested Date(s) of ervice 62 Date of ervice Not Within Allowable Inquiry Period T5 Previous Authorization Number Missing 2000F AAA 04 Follow-up Action Code Valid Values: C Please Correct and esubmit N esubmission Not Allowed 2000F UM HEALTH CAE EVICE EVIEW INFOMATION 2000F UM 01 equest Category Code Valid Values: A Admission eview H Health ervices eview C pecialty Care eview 2000F UM 02 Certification Type Code Valid Values: 2 Appeal tandard 3 Cancel (Previous equest) 4 Extension I Initial enewal - evised 2000F UM 03 ervice Type Code Valid Values: A4 Psychiatric A6 Psychotherapy A8 Psychiatric Outpatient

50 Loop Page 50 of F UM 04-1 Facility Type Code Follow Implementation Guide for this 2000F UM 04-2 Facility Code This follows the Implementation Guide for this 2000F UM 05-1 elated Causes Code Not used 2000F UM 05-2 elated Causes Code Not used 2000F UM 05-3 elated Causes Code Not used 2000F UM 05-4 tate Code Not used 2000F UM 05-5 Country Code Not used 2000F UM 05-6 Level of ervice Code Follow Implementation Guide for this NOTE: If the ervice is Emergency or Urgent, the 278 should not be used. Call OptumHealth at TELEPHONE NUMBE for authorization of these services. 2000F UM 06 Level of ervice Code Not used Valid Values: 03 Emergency U Urgent 2000F UM 07 Current Health Condition Code Not used 2000F UM 08 Prognosis Code Not used 2000F UM 09 elease of Information Code Not used 2000F UM 10 Delay eason Code Not used 2000F HC HEALTH CAE EVICE EVIEW This will be present in the esponse. It is required in the equest when UM02 = 2 Appeal tandard

51 Loop Page 51 of 55 3 Cancel (Previous equest) 4 Extension enewal - evised 2000F HC 01 Certification Action Code Valid Values: A1 Certified (Authorized) in Total A3 Not Certified (Authorized) A4 Pended A6 Modified (ee appropriate DTP ) CT Contact Payer NA No Action equired 2000F HC 02 Authorization Number OptumHealth LC Authorization Number PLEAE NOTE: This number must be returned when claims/encounters are filed for services. 2000F HC 03 eject eason Code Present when HC01 = A3 Valid Values: 53 equested ervice Inconsistent with Provider Type 69 equested ervice Inconsistent with Patient s Age 82 Not Clinically Necessary 83 Level of Care Not Appropriate 84 Authorization Not equired for this ervice 88 Non-covered ervice 90 equested Information Not

52 Loop Page 52 of F HC 04 econd urgical Opinion Indicator Not used 2000F EF PEVIOU CETIFICATION ENTIFICATION eceived 91 Duplicate equest 92 ervice Inconsistent with Diagnosis 98 Experimental ervice This segment will be present when an original request/response has been updated. 2000F EF 01 eference Identification Qualifier Valid Value: BB Authorization Number 2000F EF 02 Previous Authorization Number Previous Authorization Number 2000F DTP EVICE DATE This will be present and will contain the Date(s) services are authorized. 2000F DTP 01 Date Time Qualifier Valid Value: ervice 2000F DTP 02 Date Time Period Format Qualifier Valid Values: D8 CCYYMMDD D8 CCYYMMDD- CCYYMMDD 2000F DTP 03 ervice Date(s) ervice Date(s) 2000F DTP ADMIION DATE Not used 2000F DTP DICHAGE DATE Not used 2000F DTP UGEY DATE Not used 2000F DTP AUTHOIZATION IUE DATE This segment will provide information on the date the authorization determination was made. This follows the

53 Loop Page 53 of 55 Implementation Guide for this Transaction. 2000F DTP 01 Date Time Qualifier Valid Value: 102 Issue 2000F DTP 02 Date Time Period Format Qualifier Valid Value: D8 CCYYMMDD 2000F DTP 03 Issue Date Date Authorization Issued 2000F HI POCEDUE (EVICE) 2000F HI 01-1 Health Care Code Information Valid Value: ZZ Mutually Defined 2000F HI 01-2 Health Care Code OptumHealth LC Level of Authorized ervices 2000F HI 01-3 Date Time Period Format Qualifier Valid Values: D8 CCYYMMDD (single day) D8 CCYYMMDD-CCYYMMDD (Begin and End dates) 2000F HI 01-4 Procedure Date Authorization Date(s) 2000F HI 01-5 Procedure Amount Not used 2000F HI 01-6 Procedure Quantity Number of Units Authorized 2000F HI 01-7 Version Identifier Not used 2000F HI 02 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 03 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 04 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 05 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 06 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 07 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 08 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 09 HEALTH CODE INFOMATION ee explanation for composite above

54 Loop Page 54 of F HI 10 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 11 HEALTH CODE INFOMATION ee explanation for composite above 2000F HI 12 HEALTH CODE INFOMATION ee explanation for composite above 2000F HD HEALTH CAE EVICE DELIVE 2000F CC PATIENT CONDITION INFOMATION Not used This will be present if the equester sent the segment and will contain the equesters values. 2000F CC 01 Condition Code Category When present, will return the value submitted in 2000F CC 02 Certification Condition Indicator When present, will return the value submitted in 2000F CC 03 Condition Code When present, will return the value submitted in 2000F CC 04 Condition Code When present, will return the value submitted in 2000F CC 05 Condition Code When present, will return the value submitted in 2000F CC 06 Condition Code When present, will return the value submitted in 2000F CC 07 Condition Code When present, will return the value submitted in 2000F CL1 INTITUTIONAL CLAIM CODE Not used 2000F C1 AMBULANCE TANPOT INFOMATION 2000F NM1 EVICE LEVEL (CHIO) Not used 2000F C5 HOME OXYGEN THEAPY Not used Follow Implementation Guide for this and all data elements in this segment.

55 Loop INFOMATION 2000F C6 HOME HEALTH CAE INFOMATION 2000F PWK ADDITIONAL EVICE INFOMATION Not used Follow Implementation Guide for this and all data elements in this segment. 2000F MG MEAGE TEXT Not used E TANACTION ET TAILE Follow Implementation Guide for this and all data elements. Page 55 of 55