Finance
The Finance chapter describes Patient Accounting transactions. Other financial
transactions may be added in the future.
Financial transactions can be sent between applications either in batches or
online. As defined in Chapter 2, multiple transactions may be grouped and sent
through all file transfer media or programs when using the HL7 Encoding
Rules.
This chapter defines the transactions at the seventh level, i.e., the abstract
messages. The examples included in this chapter were constructed using the HL7
Encoding Rules.
The patient accounting message set provides for the entry and manipulation of:
charge, payment, adjustment, demographic, insurance, other related patient
billing, and accounts receivable information.
The specification includes all data defined in the National Uniform Billing
Data Element Specifications (as adapted by the National Uniform Billing
Commission, May 21, 1982 and revised November 8, 1984 and 1992). We have
excluded state-specific coding and suggest that, where required, it be
implemented in site-specific 'Z' segments. State-specific fields may be
included in the specification at a later time. In addition, no attempt has
been made to define data traditionally required for the proration of charges.
The requirement for this is unique to a billing system and not a part of an
interface.
It is recognized that a wide variety of billing and accounts receivable systems
exist today. Therefore, in an effort to accommodate the needs of the most
comprehensive systems, an extensive set of transaction segments has been
defined.
The triggering events that follow are served by the Detail Financial
Transaction (DFT), Add/Change Billing Account (BAR), and General
Acknowledgement (ACK) messages.
Each trigger event is documented below, along with the applicable form of the
message exchange. The notation used to describe the sequence, optionality, and
repetition of segments is described in Chapter 2, "Format for Defining Abstract
Messages."
Data is sent from some application (usually a Registration or an ADT system)
to the patient accounting system to establish an account for a patient's
billing/accounts receivable record. Many of the segments associated with this
event are optional. This optionality allows those systems needing these fields
to set up transactions which fulfill their requirements yet satisfy the HL7
requirements. Sample event codes are in table 0003 - event type
code.
BAR Add/Change Billing Account Chapter
MSH Message Header 2
EVN Event Type 3
PID Patient ID Information 3
{
[ PV1 ] Patient Visit 3
[ PV2 ] Patient Visit - Additional Info 3
[{ OBX }] Observation/Result 7
[{ AL1 }] Allergy Information 3
[{ DG1 }] Patient Diagnosis 6
[{ PR1 }] Procedures 6
[{ GT1 }] Guarantor 6
[{ NK1 }] Next of Kin 3
[
{
IN1 Insurance 6
[ IN2 ] Insurance - Additional Info. 6
[ IN3 ] Insurance - Add'l Info. - Cert. 6
}
]
[ACC] Accident Information 6
[UB1] Universal Bill Information 6
[UB2] Universal Bill 92 Information 6
}
The Set ID field in the insurance, diagnosis, and procedures segments will be
set the first time these segments are sent and can be used in subsequent
transactions to update them.
ACK General Acknowledgement Chapter
MSH Message Header 2
MSA Message Acknowledgement 2
[ ERR ] Error 2
The error segment will indicate the fields that caused a transaction to be
rejected.
Generally, the elimination of all billing/accounts receivable records will be
an internal function controlled by the financial system. However, on occasion,
there is a need to correct an account, or series of accounts, which may require
a notice of account deletion to be sent from another sub-system and processed
by the financial system. Although a series of accounts may be purged within
this one event, it is recommended that only one PID segment per event be
sent.
BAR Add/Change Billing Account Chapter
MSH Message Header 2
EVN Event Type 3
{
PID Patient ID Information 3
[ PV1 ] Patient Visit 3
}
ACK General Acknowledgement Chapter
MSH Message Header 2
MSA Message Acknowledgement 2
[ ERR ] Error 2
The error segment indicates the fields that caused a transaction to be
rejected.
The Detail Financial Transaction is used to describe a financial transaction
transmitted between systems, ie., to HIS for ancillary charges, ADT to HIS for
patient deposits, etc.
DFT Detail Financial Transaction Chapter
MSH Message Header 2
EVN Event Type 3
PID Patient ID Information 3
[ PV1 ] Patient Visit 3
[ PV2 ] Patient Visit - Additional Info 3
[{ OBX }] Observation/Result 7
{ FT1 } Financial Transaction 6
Special codes in the Event Type record are used for updating.
ACK General Acknowledgement Chapter
MSH Message Header 2
MSA Message Acknowledgement 2
[ ERR ] Error 2
The error segment indicates the fields that caused a transaction to be
rejected.
For patient accounting systems that support demand billing, the QRY/DSP
transaction defined in Chapter 2 will provide the mechanism to request a copy
of the bill for printing or viewing by the requesting system.
Note: This is a display-oriented response. That is why the associated
messages are defined in Chapter 2.
The FT1 segment contains detail data necessary to post charges, payments,
adjustments, etc. to patient accounting records.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
|
|
|
00355 |
Set
ID - financial transaction |
6.4.1.0 FT1 field definitions
Definition: number that uniquely identifies this transaction for the purpose
of adding, changing, or deleting the transaction.
Definition: number assigned by the sending system for control purposes. The
number can be returned by the receiving to identify errors.
Definition: uniquely identifies the batch in which this transaction belongs.
Definition: date of transaction. For example, this field would be used to
identify the date a procedure, item, or test was conducted or used. May be
defaulted to today's date.
Definition: date the transaction was sent to the financial system for
posting.
Definition: code that identifies the type of transaction. e.g., charge,
credit, payment, etc. Refer to user-defined table 0017 - transaction
type.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: code assigned by the institution for the purpose of uniquely
identifying the transaction. For example, this field would be used to uniquely
identify a procedure, item, or test for charging purposes. Refer to
user-defined table 0132 - transaction code. See Chapter 7 for
discussion on the univeral service ID.
Definition: description of the transaction associated with the code entered
in FT1-7-transaction code. This field is no longer needed as it is now
part of FT1-7-transaction code. It has been kept for backwards
compatibility.
Definition: alternate financial transaction description to be used on a site
specific basis. This field is no longer needed as it is now part of
FT1-7-transaction code. It has been kept for backwards
compatibility.
Definition: quantity of items associated with this transaction. This field
is no longer needed as it is now part of FT1-7-transaction code. It has
been kept for backwards compatibility.
Definition: amount of transaction. This field may be blank if the
transaction is automatically priced. Total price for multiple items.
Definition: unit price of transaction. Price of a single item.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: department code which controls the transaction code described
above. Refer to user-defined table 0049 - department code.
Definition: ID of the primary insurance plan this transaction should be
associated with. Refer to user-defined table 0072 - insurance plan
ID.
Definition: amount to be posted to the insurance plan referenced above.
Components: <nurse unit> ^ <room> ^ <bed> ^ <
facility ID> ^ <bed status>
Definition: current patient location. Refer to user-defined table
0079-location.
Definition: code used to select the appropriate fee schedule to be used for
this transaction posting. Refer to user-defined table 0024 - fee
schedule.
Definition: type code assigned to the patient for this visit. Refer to
user-defined table 0018 - patient type.
Components: <identifier - diagnosis code> ^ <text - diagnosis
description> ^ <name of coding system>^<alternate identifier> ^
<alternate text> ^ <name of alternate coding system>
Definition: ICD9-CM is assumed for all diagnosis codes. This diagnosis code
is the most current diagnosis code assigned to the patient. ICD10 can also be
used. Refer to user-defined table 0051 - diagnosis code.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: composite number/name of the person/group which performed the
test/procedure/transaction, etc. Refer to user defined table 0084 -
performed by table??]].
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: composite number/name of person/group which ordered the
test/procedure/transaction, etc.
Definition: unit price of transaction. The cost of a single item.
Components: <unique filler ID> ^ <filler app ID>
Definition: used when the billing system is requesting observational
reporting justification for a charge. This is the number used by a filler to
uniquely identify a result. See Chapter 4 for a complete description.
The DG1 segment contains patient diagnosis information of various types. For
example: Admitting, Current, Primary, Final, etc. Coding methodologies are
also defined.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
R |
|
00375 |
Set
ID - diagnosis |
6.4.2.0 DG1 field definitions
Definition: sequence number that uniquely identifies the individual
transaction for adding, deleting, and updating the diagnosis in the patient's
record.
Definition: ICD9 is the recommended coding methodology. Refer to
user-defined table 0053- diagnosis coding method.
Value |
Description |
I9 |
ICD9 |
Definition: diagnosis code assigned to this diagnosis. Refer to
user-defined table 0051- diagnosis code. See Chapter 7 for suggested
diagnosis codes.
Definition: description that best describes the diagnosis.
Definition: date/time the diagnosis was determined.
Definition: code identifies the type of diagnosis being sent. Valid types
could include: Admitting, Final, etc. Refer to user-defined table 0052-
diagnosis type.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: refer to user-defined table 0118 - major diagnostic
category.
Definition: DRG for the transaction. Interim DRG's could be determined for
an encounter. Refer to user-defined table 0055- DRG code.
Definition: indicates if the DRG has been approved by a reviewing entity
Definition: refer to user-defined table 0056 - DRG grouper review
code. This code indicates that the grouper results have been reviewed and
approved.
Definition: refer to user-defined table 0083 - outlier type. The type
of outlier that has been paid.
Definition: number of days that have been approved as an outlier payment.
Definition: amount of money that has been approved as a payment.
Definition: grouper version and type.
Definition: number which identifies the significance or priority of the
diagnosis or DRG code.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: individual responsible for generating the diagnosis
information.
The PR1 segment contains information relative to various types of procedures
that can be performed on a patient. For example: Surgical, Nuclear Medicine,
X-Ray with contrast, etc.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
R |
|
|
00391 |
Set
ID - procedure |
6.4.3.0 PR1 field definitions
Definition: unique number that is used to identify a transaction for the
purpose of adding, changing or deleting entries.
Definition: methodology used to assign a code to the procedure (CPT4 for
example). If more than one coding method is needed for a single procedure,
this field and associated PR1-3-procedure code and PR1-4-procedure
description may repeat. In this instance, the three fields (PR1-2
through 4) are directly associated with one another. Refer to
user-defined table 0089 - procedure coding method for suggested
values.
Definition: unique identifier assigned to the procedure. Refer to
user-defined table 0088 - procedure code for suggested values.
Definition: text description that describes the procedure.
Definition: date/time the procedure was performed.
Definition: optional code that further defines the type of procedure. Refer
to user-defined table 0090 - procedure type for suggested values.
Definition: length of time in whole minutes that the procedure took to
complete.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: Anesthesiologist who administered the anesthesia. It is
recommended that PR1-12-procedure MD be used instead of this field.
This field remains only for backward compatibility. Refer to user-defined
table 0010 - physician ID.
Definition: uniquely identifies the anesthesia used during the procedure. It
is recommended that PR1-12-procedure MD be used instead of this field.
This field remains only for backward compatibility.
Definition: length of time in minutes that the anesthesia was administered.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: surgeon who performed the procedure. It is recommended that
PR1-12-procedure MD be used instead of this field. This field remains
only for backward compatibility. Refer to user-defined table 0010 -
physician ID.
Components: <procedure practitioner ID>(CN) ^ <procedure
practitioner type>(ID)
Definition: different types of practitioners associated with this procedure.
The ID and name components follow the standard rules defined for a composite
name (CN) field. If the procedure type component is unvalued, it is assumed
that the physician identified is a resident. Refer to user-defined table
0010 - physician ID. Refer to user-defined table 0133 - procedure
practitioner type for suggested entries.
Value |
Description |
AN |
Anesthesiologist |
Definition: type of consent that was obtained for permission to treat the
patient. Refer to user-defined table 0059 - consent code.
Definition: number which identifies the significance or priority of the
procedure code.
The GT1 segment contains guarantor (e.g., person with financial responsibility
for payment of a patient account) data for patient and insurance billing
applications.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
R |
|
|
00405 |
Set
ID - guarantor |
6.4.4.0 GT1 field definitions
Definition: number that uniquely identifies the transaction for the purpose
of adding, changing, or deleting a transaction.
Definition: unique number assigned to the guarantor.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: name of the guarantor.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: name of the guarantor's spouse.
Components: <street address> ^ < other designation> ^
<city> ^ <state or province> ^ <zip or postal code> ^
<country> ^ <type> ^ <other geographic designation>
Definition: guarantor's address.
Definition: guarantor's home phone number.
Definition: guarantor's business phone number.
Definition: guarantor's date of birth.
Definition: refer to table 0001 - sex for valid entries.
Definition: type of guarantor, e.g., individual, institution, etc. Refer to
user-defined table 0068 - guarantor type.
Definition: relationship of the guarantor with the patient, e.g., parent,
child, etc. Refer to user-defined table 0063 - guarantor
relationship.
Definition: guarantor's social security number.
Definition: date the guarantor becomes responsible for the patient's account.
Definition: date the guarantor stops being responsible for the patient's
account.
Definition: used to determine the order in which the guarantors will be
responsible for the patient's account.
Definition: name of the guarantor's employer.
Components: <street address> ^ < other designation> ^
<city> ^ <state or province> ^ <zip or postal code> ^
<country> ^ <type> ^ <other geographic designation>
Definition: guarantor's employer's address.
Definition: guarantor's employer phone number.
Definition: guarantor's employee number.
Definition: code that indicates the guarantor's employment status. e.g., Full
Time, Part Time, Self Employed, etc. Refer to user-defined table 0066 -
employment status.
Definition:
The IN1 segment contains insurance policy coverage information necessary to
produce properly pro-rated and patient and insurance bills.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
R |
|
|
00426 |
Set
ID - insurance |
6.4.5.0 IN1 field definitions
Definition: sequence number which uniquely identifies this transaction for
the purpose of adding, changing, or deleting the transaction.
Definition: uniquely identifies the insurance plan. Refer to user-defined
table 0072 - insurance plan ID. To eliminate a plan, the plan could be
sent with null values in each subsequent element. If the respective systems
can support it, a null value can be sent in the plan field.
Definition: uniquely identifies the insurance company.
Definition: name of the insurance company.
Components: <street address> ^ < other designation> ^
<city> ^ <state or province> ^ <zip or postal code> ^
<country> ^ <type> ^ <other geographic designation>
Definition: address of the insurance company.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: name of the person who should be contacted at the insurance
company.
Definition: phone number of the insurance company.
Definition: group number of the insured's insurance.
Definition: group name of the insured's insurance.
Definition: group employer ID of the insured's insurance.
Definition: name of the employer which provides the employee's insurance.
Definition: date that the insurance goes into effect.
Definition: last date of service that the insurance will cover or be
responsible for.
Components: <authorization number>(ST) ^ <date> ^
<source>
Definition: based on the type of insurance, some coverages require that an
authorization number or code be obtained prior to all non emergency admissions
and within 48 hours of an emergency admission. Insurance billing would not
be permitted without this number. Date and source of authorization are
sub-fields.
Definition: coding structure that identifies the various plan types. Refer
to user-defined table 0086 - plan ID.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: name of the insured person.
Definition: insured's relationship to the patient. Refer to user-defined
table 0063 - relationship.
Definition: date of birth of insured.
Components: <street address> ^ < other designation> ^
<city> ^ <state or province> ^ <zip or postal code> ^
<country> ^ <type> ^ <other geographic designation>
Definition: address of insured person.
Definition: has the insured agreed to assign the insurance benefits to the
healthcare provider? If so, the insurance will pay the provider directly.
Refer to user-defined table 0135 - assignment of benefits for suggested
values.
Value |
Description |
Y |
Yes |
Definition: does this insurance work in conjunction with other insurance
plans, or does it provide independent coverage and payment of benefits
regardless of other insurance that might be available to the patient? Refer to
user-defined table 0173 - coordination of benefits for suggested values.
Value |
Description |
CO |
Coordination |
Definition: if the insurance works in conjunction with other insurance plans,
what is priority sequence? Values are: 1, 2, 3, etc.
Definition: does the insurance require a written notice of admission from the
healthcare provider? Refer to table 0136 - Y/N indicator for valid
values.
Definition: if a notice is required, this is the date that it was sent.
Definition: does this insurance carrier send a report which indicates that
the patient is eligible for benefits and identifies those benefits? Refer to
table xxxx - Y/N indicator for valid values.
Definition: if a report of eligibility (ROE) was received, this indicates the
date it was received.
Definition: can the healthcare provider release information about the
patient, and what information can be released. Refer to user-defined table
0093 - release information code for suggested values.
Value |
Description |
Y |
Yes |
Definition: pre-admission certification code. If the admission must be
certified before the admission, this is the code associated with the admission.
Definition: date/time that the healthcare provider verified that the patient
has the indicated benefits.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: person that verified the benefits.
Definition: used to further identify an insurance plan. Refer to
user-defined table 0098 - type of agreement code for suggested values.
Suggested values are standard, unified, or maternity.
Definition: has the particular insurance been billed and if so, what type of
bill. Refer to user-defined table 0022 - billing status for suggested
values.
Definition: number of days left where a certain service may be provided or
covered under an insurance policy.
Definition: delay before lifetime reserve days.
Definition: Refer to user-defined table 0042 - company plan code.
This table contains codes used to uniquely identify an insurance plan.
Optional information to further define data in IN1-3-insurance company
ID.
Definition: individual policy number of the insured.
Definition: amount specified by the insurance plan that is the responsibility
of the guarantor.
Definition: maximum amount that the insurance policy will pay. In some
cases, the limit may be for a single encounter.
Definition: maximum number of days that the insurance policy will cover.
Definition: average room rate that the policy will cover. It is recommended
that IN2-28-room coverage type/amount be used instead of this field.
This field remains only for backward compatibility.
Definition: maximum private room rate the policy will cover. It is
recommended that IN2-28-room coverage type/amount be used instead of
this field. This field remains only for backward compatibility.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: refer to user-defined table 0066 - employment status for
valid codes.
Definition: refer to table 0001 - sex for valid codes.
Components: <street address> ^ < other designation> ^
<city> ^ <state or province> ^ <zip or postal code> ^
<country> ^ <type> ^ <other geographic designation>
Definition: address of the insured employee.
Definition: status of this patient's relationship with this insurance
carrier.
Definition: uniquely identifies the prior insurance plan when the plan ID
changes. Refer to user-defined table 0072 - insurance plan ID.
The IN2 segment contains additional insurance policy coverage and benefit
information necessary for proper billing and reimbursement. Fields used by
this segment are defined by HICFA or other regulatory agencies.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
15 |
ST |
|
|
00472 |
Insured's
employee ID |
6.4.6.0 IN2 field definitions
Definition: employee ID of insured.
Definition: social security number of insured.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: name of insured's employer.
Definition: required employer information data for UB82 form locator 71.
Refer to user-defined table 0139 - employer information data for
suggested values.
Definition: party to which the claim should be mailed.
Value |
Description |
E |
Employer |
Definition: this field is defined by HCFA or other regulatory agencies.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: this field is defined by HCFA or other regulatory agencies.
Definition: this field is defined by HCFA or other regulatory agencies.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: this field is defined by HCFA or other regulatory agencies.
Definition: this field is defined by HCFA or other regulatory agencies.
Definition: defined by HCFA or other regulatory agencies.
Definition: defined by HCFA or other regulatory agencies.
Definition: defined by HCFA or other regulatory agencies.
Definition: defined by HCFA or other regulatory agencies. Refer to table
0140 - Champus service for suggested values.
Definition: This user-defined field identifies the CHAMPUS military
rank/grade of the insured. Refer to table 0141 - Champus rank/grade for
suggested values.
Definition: defined by HCFA or other regulatory agencies. Refer to table
0142 - Champus status for suggested values.
Definition: defined by HCFA or other regulatory agencies.
Definition: refer to table 0136 - Y/N indicator.
Definition: refer to table 0136 - Y/N indicator.
Definition: refer to table 0136 - Y/N indicator.
Definition: it is recommended that this field be used instead of
UB2-2-blood deductible as the blood deductible can be associated with
the specific insurance plan via this field.
Components: <family name> ^ <given name> ^ <middle initial
or name> ^ <suffix (e.g., JR or III)> ^ <prefix (e.g., DR)> ^
<degree (e.g., MD)>
Definition: name of the individual that approves any special coverage.
Definition: title of the person that approves special coverage.
Definition: code which describes why a service is not covered. Refer to
user-defined table 0143 - non-covered insurance code for suggested
values.
Definition: required for NEIC processing, identifies the organization from
which reimbursement is expected.
Definition: required for NEIC processing, identifies the specific office
within the insurance carrier designated as responsible for the claim.
Definition: required for NEIC processing, identifies the source of
information about the insured's eligibility for benefits. Refer to
user-defined table 0144 - eligibility source for suggested entries.
Value |
Description |
1 |
Insurance
company |
Components: <room type (ID)> ^ <amount type (ID)> ^
<coverage amount(NM)>
Definition: room type (e.g., private, semi-private) and amount (e.g., rate,
percentage, differential) covered by the insurance. It is recommended that
this field be used instead of IN1-40-room rate - semi-private and
IN1-41-room rate - private. Refer to user-defined tables 0145 - room
type and 0146 - amount type for suggested entries.
Value |
Description |
PRI |
Private
room |
Value |
Description |
DF |
Differential |
Components: <policy type (ID)> ^ <amount class (ID)> ^
<amount (NM)>
Definition: policy type (e.g., ancillary, major medical) and amount (e.g.,
amount, percentage, limit) covered by the insurance. It is recommended that
this field is used instead of IN1-38-policy limit - amount. Refer to
user-defined tables 0147 - policy type and 0193 - amount class
for suggested entries.
Value |
Description |
ANC |
Ancillary |
Value |
Description |
AT |
Amount |
Components: <delay days> ^ <amount> ^ <number of
days>
Definition: number of days after which to begin the daily deductible, the
amount of the deductible, and the number of days to apply the deductible.
The IN3 segment contains additional insurance information for certifying the
need for patient care. Fields used by this segment are defined by HICFA or
other regulatory agencies.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
R |
|
|
00502 |
Set
ID - insurance certification |
6.4.7.0 IN3 field definitions
Definition: sequence number which uniquely identifies this segment for the
purpose of adding, changing, or deleting a certification segment.
Definition: assigned by the certification agency.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: party that approved the certification.
Definition: identifies whether certification is required. Refer to table
0136 - Y/N indicator for valid values.
Components: <penalty type (ID)> ^ <penalty amount>
Definition: the penalty, in dollars or a percentage, that will be assessed if
the pre-certification is not performed. Refer to user-defined table 0148 -
penalty type for suggested entries.
Value |
Description |
AT |
Currency
amount |
Definition: date and time stamp when insurance was certified to exist for the
patient.
Definition: date/time that the certification was modified.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: party that is responsible for sending this certification
information.
Definition: date that this certification begins.
Definition: date that this certification ends.
Components: <day type (ID)> ^ <number of days (NM)>
Definition: number of days for which this certification is valid. This field
will apply to denied, pending, or approved days. Refer to user-defined
table 0149 - day type for suggested entries.
Value |
Description |
AP |
Approved |
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: non-concur code and description for a denied request.
Definition: effective date of the non-concurrence classification.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: physician who works with and reviews cases that are pending
physician review for the certification agency.
Definition: name of the party contacted at the certification agency who
granted the certification and communicated the certification number.
Definition: phone number of the certification contact.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: reason an appeal was made on a non-concur for certification.
Components: <identifier> ^ <text> ^ <name of coding
system>^<alternate identifier> ^ <alternate text> ^ <name of
alternate coding system>
Definition: certification agency.
Definition: phone number of the Certification agency.
Components: <pre-certification patient type (ID)> ^
<pre-certification required (ID)> ^ <pre-certification window
(TS)>
Definition: identifies whether pre-certification is required for particular
patient types and the time window for obtaining the certification. Refer to
user-defined table 0150 - pre-certification patient type for suggested
values. Valid values for the pre-certification required component are found in
table 0136 - Y/N indicator. The pre-certification window is the amount
of time needed to be certified from arrival at the institution. Its format
follows the time stamp (TS) data type rules.
Value |
Description |
ER |
Emergency |
Definition: entity who/which is handling this particular patient's case
(e.g., UR nurse, or a specific facility location).
Definition: date that the second opinion was obtained.
Definition: Code that represents the status of the second opinion. Refer to
user-defined table 0151 - second opinion status for suggested values.
Definition: if accompanying documentation has been received by the provider.
Refer to table 0152 - second opinion documentation received.
Components: <ID Number> ^ <family name> ^ <given name>
^ <middle initial or name> ^ <suffix (e.g., JR or III)> ^
<prefix (e.g., DR)> ^ <degree (e.g., MD)> ^ <source
table>
Definition: ID and name of the physician who provided the second opinion.
The ACC segment contains patient information relative to an accidentin which
the patient has been involved.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
26 |
TS |
|
00527 |
Accident
date/time |
6.4.8.0 ACC field definitions
Definition: date/time of the accident.
Definition: type of accident. Refer to user-defined table 0050 - accident
code.
Definition: location of the accident.
The UB1 segment contains data necessary to complete UB82 bills. Only UB82
data elements that do not exist in other HL7 defined segments will appear in
this segment. Patient name and Date of Birth are required for UB82 billing,
however, they are included in the PID segment and therefore do not appear here.
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
|
|
00530 |
Set
ID - UB82 |
6.4.9.0 UB1 field definitions
Definition: number used to uniquely identify the transaction for the purpose
of adding, changing, or deleting the entry.
Definition: It is recommended that IN2-21-blood deductible be used
instead of this field as the blood deductible can be associated with the
specific insurance plan via that segment.
Definition: amount of blood furnished the patient for this visit. The (40)
indicates the corresponding UB82 Data Element number.
Definition: UB82 Data Element 41.
Definition: Blood not replaced. Measured in pints. UB82 Data Element 42
Definition: UB82 Data Element 25.
Definition: repeats 5 times. UB82 Data Elements (35), (36), (37), (38),and
(39). Refer to user-defined table 0043 - condition code for suggested
values.
Definition: UB82 Data Element 23.
Definition: UB82 Data Element 24.
Components: <value code (ID)> ^ <value amount (NM)>
Definition: pair can repeat up to eight times. (46A, 47A, 48A, 49A, 46B,
47B, 48B, and 49B). Refer to user-defined table 0153 - value code for
suggested values.
Definition: UB82 Data Element 90.
Definition: special program indicator. UB82 Data Element 44.
Definition: PSRO/UR approval indicator. UB82 data element 87.
Definition: PSRO/UR approved stay date (from). UB82 Data Element 88.
Definition: PSRO/UR approved stay date (to). UB82 Data Element 89.
Components: <occurrence code (ID)> ^ <occurrence date
(DT)>
Definition: set of values can repeat up to five times. UB82 Data Elements
28-32.
Definition: UB82 Data Element 33.
Definition: occurrence span start date. UB82 Data Element 33.
Definition: occurrence span end date. UB82 Data Element 33.
Definition: defined by UB-82 HICFA specification.
Definition: defined by UB-82 HICFA specification.
Definition: defined by UB-82 HICFA specification.
Definition: defined by UB-82 HICFA specification.
The UB2 segment contains data necessary to complete UB92 bills. Only UB92
data elements that do not exist in other HL7 defined segments will appear in
this segment. Just as with the UB82 billing, Patient Name and Date of
Birth are required, they are included in the PID segment and therefore do not
appear here. Where the field locators are different on the UB92, when compared
to the UB82, the element is listed with its new location in parentheses ().
SEQ |
LEN |
DT |
R/O |
RP/# |
TBL# |
ITEM# |
ELEMENT NAME |
|---|---|---|---|---|---|---|---|
1 |
4 |
SI |
|
|
00553 |
Set
ID - UB92 |
6.4.10.0 UB2 field definitions
Definition: number used to uniquely identify the transaction for the purpose
of adding, changing, or deleting the entry.
Definition: UB92 data element 9.
Definition: repeats up to seven times. UB92 data elements 24-30. Refer to
user-defined table 0043 - condition code.
Definition: UB92 data element 7.
Definition: UB92 data element 8.
Components: <value code> ^ <value amount>
Definition: pair can repeat up to 12 times. UB92 data elements 39a, 39b,
39c, 39d, 40a, 40b, 40c, 40d, 41a, 41b, 41c, 41d.
Components: <occurrence code (ID)> ^ <occurrence date
(DT)>
Definition: set of values can repeat up to eight times. UB92 data elements
32a, 32b, 33a, 33b, 34a, 34b, 35a, 35b.
Components: <occurrence span code (ID)> ^ <occurrence span start
date (DT)> ^ <occurrence span stop date (DT)>
Definition: can repeat up to two times. UB92 data element 36a, 36b.
Definition: may repeat up to two times.
Definition: may repeat up to two times.
Definition: defined by HICFA or other regulatory agencies.
Definition: number assigned by payor. Used for rebilling/adjustment
purposes. May repeat up to 3 times. UB92 data element 37.
Definition: may repeat up to 23 times.
Definition: may repeat up to five times.
Definition: defined by UB-92 HICFA specification.
Definition: may repeat up to two times.
MSH|^~\&|FDCHSG|01|ROUTER|01|19930908135031||ADT^AO1|641|P|2.1|000000000000001|
EVN|A01|1993090813503||
PID||0008064993|0008064993||0006045681|SMITH^PAT^J^^^||19930506|F|^^^^^|1|1234
FANNIN^^HOUSTON^TX^77030^|USA|HAR||||S||6045681|000000000|^
GT1|001||JOHNSON^SAM^J||8339 MORVEN RD^BALTIMORE^MD^
21234^""||||||193-22-1876<CR>
NK1|JOHNSON^WILLIAM|F|522 MAIN ST^CUMBERLAND^MD
^28765^""|(301)555-2134<CR> IN1|001|A|A357|BCMD|||||
132987<CR>
A patient has been registered by the ADT system (PATA) and notification is
sent to the Patient Billing system (PATB). The patient's name is Sam J.
Johnson, a Male Caucasian, born on October 7, 1947. Living at 8339 Morven Rd,
Baltimore, MD.
Mr. Johnson's patient number is 125976 and his billing number is 125976011.
Mr. Johnson has provided his father's name and address as next of kin. Mr.
Johnson is insured under plan ID A357 with an insurance company known to both
systems as BCMD.
MSH|^~\&|UREV||PATB||||BAR^P01|MSG0018|P|VRS1.0<CR>
PID|||125976||JOHNSON^SAM^J|||||||||||||125976011<CR>
UB1|1|5|3|1||1^36|||220|76|1|19880501|19880522<CR>
Utilization review sends data for Patient Billing to the Patient Accounting
system. The patient's insurance program has a 1 pint deductible for blood, the
patient received 5 pints of blood, and 3 pints were replaced, with 1 pint not
yet replaced. There is a UB82 Condition code 1.
The patient has been assigned to a Special Unit because no general care beds
are available (UB82 condition code 36). Additionally, the patient has been
scheduled for out-patient pre-admission diagnostic services in preparation for
a previously scheduled admission, the cost of these services is $220. The
patient's services are related to a special program, defined by the Insurance
Plan as plan 76.
The services provided for the period 05/01/88 through 05/22/88 are fully
approved (PSRO/UR Approval Code 1), including any day or cost outlier.
MSH|^~\&|UREV||PATB||||BAR^P01|MSG0018|P|VRS1.0<CR>
PID|||125976||JOHNSON^SAM^J|||||||||||||125976011<CR>
DG1|001|I9|1550|MAL NEO LIVER, PRIMARY|19880501|DG<CR>
DG1|002||||19880501|DR||203|||DY|5<CR>
The first Diagnosis segment, contains the information that the patient has
been diagnosed on May 1, as having a malignancy of the Hepatobiliary System or
Pancreas (ICD9 code 1550). In the second segment, the patient has been
assigned a Diagnostic Related Group (DRG) of 203 (corresponding to the ICD9
code of 1550). Also, the patient has been approved for an additional 5 days
(5 day outlier).
ID Codes used:
element 3.0 Diagnosis Coding Methodology I9 = ICD9
element 8.0 Diagnosis/DRG Type
DG = Diagnosis
DR = DRG
element 13.0 Outlier type
DY = Day Outlier
The SET-ID used to be needed to identify whether or not a record was to be
used for deletion, update, or cancellation. This was redundant since the event
type indicates this fact. Consequently, the SET-ID is now only used to
uniquely identify a segment.
None.
ACC 6-30
DG1 6-7
Finance 6-1
FT1 6-4
GT1 6-12
IN1 6-15
IN2 6-21
IN3 6-26
P01 6-2
P02 6-2
P03 6-3
P04 6-3
Patient Accounting 6-1
PR1 6-9
Segments
ACC 6-30
DG1 6-7
FT1 6-4
GT1 6-12
IN1 6-15
IN2 6-21
IN3 6-26
PR1 6-9
UB1 6-31
UB2 6-34
Trigger Event
P01 6-2
P02 6-2
P03 6-3
P04 6-3
UB1 6-31
UB2 6-34