278 Health Care Services Review: Request for Review and Response (004010X094A1)

Providers send the 278 to request prior authorization or referral review, and payers use it to respond. This is the standard X12 HIPAA 004010 spec, with 34 loops and 203 segment positions, as OpenEDI JSON, an ediFabric C# template and an ediFabric Native model. To change it for a trading partner, customize it in the EDI Spec Builder.

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The spec as an OpenAPI 3 schema with x-openedi-* extensions, for ediFabric Native, ediFabric Cloud and the EDI Spec Builder. Download OpenEDI (206 KB) Generate classes

The ediFabric .NET template, class TS278. The download includes the common segments, composites and codes it needs. Download C# (53 KB)

The intermediary model ediFabric Native loads with set_map. Download Native (114 KB)

Use the 278 spec in your code

ediFabric .NET

Add the C# template and its common files to your project, or reference the template NuGet package, and read 278 files into TS278 objects. See ediFabric .NET.

ediFabric Native

Map version 004010X094A1 to the Native model with set_map, then parse 278 files to JSON from Python, Java, C or C#. See Convert between EDI and JSON.

OpenEDI

Select Customize in Spec Builder to copy the spec under your own name, change it for your partner, and parse files against it in EdiNation, ediFabric Native or ediFabric Cloud. Read about OpenEDI.

Generate 278 classes in Python, Java, Node.js, Go, Rust or C

ediFabric Native returns each 278 as JSON, with the property names of the OpenEDI schema. To work with that JSON as typed objects, generate classes from the OpenEDI file in your language and deserialize the JSON into TS278. Serialize the objects back to JSON to build EDI with ediFabric Native. The classes keep the loops, segments, lengths and code lists, but not the EDI data formats, so validate files with ediFabric Native. Read more in Generate a class from OpenEDI.

Python: datamodel-code-generator. Node.js: openapi-typescript. Java, Go, Rust and C: OpenAPI Generator.

For a sample file, the same data as JSON, and code to parse, validate and generate the 278, see the 278 transaction guide.

278 structure

Loops and segments of the standard 278, with their usage and maximum repeats.

ID	Name	Usage	Max use
ST	Transaction Set Header	Optional	1
Loop BHT	Beginning Of Hierarchical Transaction	Optional	1
BHT	Beginning Of Hierarchical Transaction	Optional	1
Loop HL	Utilization Management Organization UMO Level	Optional	1
HL	Utilization Management Organization UMO Level	Mandatory	1
Loop NM1	Utilization Management Organization UMO Name	Mandatory	1
NM1	Utilization Management Organization UMO Name	Mandatory	1
Loop HL	Requester Level	Mandatory	1
HL	Requester Level	Mandatory	1
Loop NM1	Requester Name	Mandatory	1
NM1	Requester Name	Mandatory	1
REF	Requester Supplemental Identification	Optional	8
N3	Requester Address	Optional	1
N4	Requester City State ZIP Code	Optional	1
PER	Requester Contact Information	Optional	1
PRV	Requester Provider Information	Optional	1
Loop HL	Subscriber Level	Mandatory	1
HL	Subscriber Level	Mandatory	1
TRN	Patient Event Tracking Number	Optional	2
DTP	Accident Date	Optional	1
DTP	Last Menstrual Period Date	Optional	1
DTP	Estimated Date Of Birth	Optional	1
DTP	Onset Of Current Symptoms Or Illness Date	Optional	1
HI	Subscriber Diagnosis	Optional	1
PWK	Additional Patient Information	Optional	10
Loop NM1	Subscriber Name 2010CA	Mandatory	1
NM1	Subscriber Name 2010CA	Mandatory	1
REF	Subscriber Supplemental Identification 2010CA	Optional	9
DMG	Subscriber Demographic Information 2010CA	Optional	1
Loop HL	Dependent Level	Optional	1
HL	Dependent Level	Mandatory	1
TRN	Patient Event Tracking Number	Optional	2
DTP	Accident Date	Optional	1
DTP	Last Menstrual Period Date	Optional	1
DTP	Estimated Date Of Birth	Optional	1
DTP	Onset Of Current Symptoms Or Illness Date	Optional	1
HI	Dependent Diagnosis	Optional	1
PWK	Additional Patient Information	Optional	10
Loop NM1	Dependent Name 2010DA	Mandatory	1
NM1	Dependent Name 2010DA	Mandatory	1
REF	Dependent Supplemental Identification 2010DA	Optional	3
DMG	Dependent Demographic Information 2010DA	Optional	1
INS	Dependent Relationship 2010DA	Optional	1
Loop HL	Service Provider Level	Mandatory	>1
HL	Service Provider Level	Mandatory	1
MSG	Message Text	Optional	1
Loop NM1	Service Provider Name	Mandatory	3
NM1	Service Provider Name	Mandatory	1
REF	Service Provider Supplemental Identification	Optional	7
N3	Service Provider Address	Optional	1
N4	Service Provider City State ZIP Code	Optional	1
PER	Service Provider Contact Information	Optional	1
PRV	Service Provider Information	Optional	1
Loop HL	Service Level	Mandatory	>1
HL	Service Level	Mandatory	1
TRN	Service Trace Number	Optional	2
UM	Health Care Services Review Information	Mandatory	1
REF	Previous Certification Identification	Optional	1
DTP	Service Date	Optional	1
DTP	Admission Date	Optional	1
DTP	Discharge Date	Optional	1
DTP	Surgery Date	Optional	1
HI	Procedures	Optional	1
HSD	Health Care Services Delivery	Optional	1
CRC	Patient Condition Information	Optional	6
CL1	Institutional Claim Code	Optional	1
CR1	Ambulance Transport Information	Optional	1
CR2	Spinal Manipulation Service Information	Optional	1
CR5	Home Oxygen Therapy Information	Optional	1
CR6	Home Health Care Information	Optional	1
PWK	Additional Service Information	Optional	10
MSG	Message Text	Optional	1
Loop HL	Service Provider Level	Optional	>1
HL	Service Provider Level	Mandatory	1
MSG	Message Text	Optional	1
Loop NM1	Service Provider Name	Mandatory	3
NM1	Service Provider Name	Mandatory	1
REF	Service Provider Supplemental Identification	Optional	7
N3	Service Provider Address	Optional	1
N4	Service Provider City State ZIP Code	Optional	1
PER	Service Provider Contact Information	Optional	1
PRV	Service Provider Information	Optional	1
Loop HL	Service Level	Mandatory	>1
HL	Service Level	Mandatory	1
TRN	Service Trace Number	Optional	2
UM	Health Care Services Review Information	Mandatory	1
REF	Previous Certification Identification	Optional	1
DTP	Service Date	Optional	1
DTP	Admission Date	Optional	1
DTP	Discharge Date	Optional	1
DTP	Surgery Date	Optional	1
HI	Procedures	Optional	1
HSD	Health Care Services Delivery	Optional	1
CRC	Patient Condition Information	Optional	6
CL1	Institutional Claim Code	Optional	1
CR1	Ambulance Transport Information	Optional	1
CR2	Spinal Manipulation Service Information	Optional	1
CR5	Home Oxygen Therapy Information	Optional	1
CR6	Home Health Care Information	Optional	1
PWK	Additional Service Information	Optional	10
MSG	Message Text	Optional	1
Loop BHT	Beginning Of Hierarchical Transaction	Optional	1
BHT	Beginning Of Hierarchical Transaction	Optional	1
Loop HL	Utilization Management Organization UMO Level	Optional	1
HL	Utilization Management Organization UMO Level	Mandatory	1
AAA	Request Validation	Optional	9
Loop NM1	Utilization Management Organization UMO Name	Mandatory	1
NM1	Utilization Management Organization UMO Name	Mandatory	1
PER	Utilization Management Organization UMO Contact Information	Optional	1
AAA	Utilization Management Organization UMO Request Validation	Optional	9
Loop HL	Requester Level	Mandatory	1
HL	Requester Level	Mandatory	1
Loop NM1	Requester Name	Mandatory	1
NM1	Requester Name	Mandatory	1
REF	Requester Supplemental Identification	Optional	8
AAA	Requester Request Validation	Optional	9
PRV	Requester Provider Information	Optional	1
Loop HL	Subscriber Level	Mandatory	1
HL	Subscriber Level	Mandatory	1
TRN	Patient Event Tracking Number	Optional	3
AAA	Subscriber Request Validation	Optional	9
DTP	Accident Date	Optional	1
DTP	Last Menstrual Period Date	Optional	1
DTP	Estimated Date Of Birth	Optional	1
DTP	Onset Of Current Symptoms Or Illness Date	Optional	1
HI	Subscriber Diagnosis	Optional	1
PWK	Additional Patient Information	Optional	10
Loop NM1	Subscriber Name 2010CA	Mandatory	1
NM1	Subscriber Name 2010CA	Mandatory	1
REF	Subscriber Supplemental Identification 2010CA	Optional	9
AAA	Subscriber Request Validation 2010CA	Optional	9
DMG	Subscriber Demographic Information 2010CA	Optional	1
Loop NM1	Additional Patient Information Contact Name 2010CB	Optional	1
NM1	Additional Patient Information Contact Name 2010CB	Mandatory	1
N3	Additional Patient Information Contact Address 2010CB	Optional	1
N4	Additional Patient Information Contact City State Zip Code 2010CB	Optional	1
PER	Additional Patient Information Contact Information 2010CB	Optional	1
Loop HL	Dependent Level	Optional	1
HL	Dependent Level	Mandatory	1
TRN	Patient Event Tracking Number	Optional	3
AAA	Dependent Request Validation	Optional	9
DTP	Accident Date	Optional	1
DTP	Last Menstrual Period Date	Optional	1
DTP	Estimated Date Of Birth	Optional	1
DTP	Onset Of Current Symptoms Or Illness Date	Optional	1
HI	Dependent Diagnosis	Optional	1
PWK	Additional Patient Information	Optional	10
Loop NM1	Dependent Name 2010DA	Mandatory	1
NM1	Dependent Name 2010DA	Mandatory	1
REF	Dependent Supplemental Identification 2010DA	Optional	3
AAA	Dependent Request Validation 2010DA	Optional	9
DMG	Dependent Demographic Information 2010DA	Optional	1
INS	Dependent Relationship 2010DA	Optional	1
Loop NM1	Additional Patient Information Contact Name 2010DB	Optional	1
NM1	Additional Patient Information Contact Name 2010DB	Mandatory	1
N3	Additional Patient Information Contact Address 2010DB	Optional	1
N4	Additional Patient Information Contact City State Zip Code 2010DB	Optional	1
PER	Additional Patient Information Contact Information 2010DB	Optional	1
Loop HL	Service Provider Level	Mandatory	>1
HL	Service Provider Level	Mandatory	1
MSG	Message Text	Optional	1
Loop NM1	Service Provider Name	Mandatory	3
NM1	Service Provider Name	Mandatory	1
REF	Service Provider Supplemental Identification	Optional	7
N3	Service Provider Address	Optional	1
N4	Service Provider City State ZIP Code	Optional	1
PER	Service Provider Contact Information	Optional	1
AAA	Service Provider Request Validation	Optional	9
PRV	Service Provider Information	Optional	1
Loop HL	Service Level	Mandatory	>1
HL	Service Level	Mandatory	1
TRN	Service Trace Number	Optional	3
AAA	Service Request Validation	Optional	9
UM	Health Care Services Review Information	Mandatory	1
HCR	Health Care Services Review	Optional	1
REF	Previous Certification Identification	Optional	1
DTP	Service Date	Optional	1
DTP	Admission Date	Optional	1
DTP	Discharge Date	Optional	1
DTP	Surgery Date	Optional	1
DTP	Certification Issue Date	Optional	1
DTP	Certification Expiration Date	Optional	1
DTP	Certification Effective Date	Optional	1
HI	Procedures	Optional	1
HSD	Health Care Services Delivery	Optional	1
CL1	Institutional Claim Code	Optional	1
CR1	Ambulance Transport Information	Optional	1
CR2	Spinal Manipulation Service Information	Optional	1
CR5	Home Oxygen Therapy Information	Optional	1
CR6	Home Health Care Information	Optional	1
PWK	Additional Service Information	Optional	10
MSG	Message Text	Optional	1
Loop NM1	Additional Service Information Contact Name	Optional	1
NM1	Additional Service Information Contact Name	Mandatory	1
N3	Additional Service Information Contact Address	Optional	1
N4	Additional Service Information Contact City State Zip Code	Optional	1
PER	Additional Service Information Contact Information	Optional	1
Loop HL	Service Provider Level	Optional	>1
HL	Service Provider Level	Mandatory	1
MSG	Message Text	Optional	1
Loop NM1	Service Provider Name	Mandatory	3
NM1	Service Provider Name	Mandatory	1
REF	Service Provider Supplemental Identification	Optional	7
N3	Service Provider Address	Optional	1
N4	Service Provider City State ZIP Code	Optional	1
PER	Service Provider Contact Information	Optional	1
AAA	Service Provider Request Validation	Optional	9
PRV	Service Provider Information	Optional	1
Loop HL	Service Level	Mandatory	>1
HL	Service Level	Mandatory	1
TRN	Service Trace Number	Optional	3
AAA	Service Request Validation	Optional	9
UM	Health Care Services Review Information	Mandatory	1
HCR	Health Care Services Review	Optional	1
REF	Previous Certification Identification	Optional	1
DTP	Service Date	Optional	1
DTP	Admission Date	Optional	1
DTP	Discharge Date	Optional	1
DTP	Surgery Date	Optional	1
DTP	Certification Issue Date	Optional	1
DTP	Certification Expiration Date	Optional	1
DTP	Certification Effective Date	Optional	1
HI	Procedures	Optional	1
HSD	Health Care Services Delivery	Optional	1
CL1	Institutional Claim Code	Optional	1
CR1	Ambulance Transport Information	Optional	1
CR2	Spinal Manipulation Service Information	Optional	1
CR5	Home Oxygen Therapy Information	Optional	1
CR6	Home Health Care Information	Optional	1
PWK	Additional Service Information	Optional	10
MSG	Message Text	Optional	1
Loop NM1	Additional Service Information Contact Name	Optional	1
NM1	Additional Service Information Contact Name	Mandatory	1
N3	Additional Service Information Contact Address	Optional	1
N4	Additional Service Information Contact City State Zip Code	Optional	1
PER	Additional Service Information Contact Information	Optional	1
SE	Transaction Set Trailer	Optional	1