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Referral / Authorization

The ASC X12N Health Care Services Review – Request for Review and Response (278) is a paired transaction set consisting of a Request (278) and a Response (278).  This transaction set is also known informally by other names, such as Referral or Prior Authorization.

The Request for Review allows a healthcare provider to request authorization from a health plan or utilization management organization for:  

  • A referral to a specialist
  • A hospital admission
  • A healthcare service or supply

The Request for Review supports an initial request or a revision to a previous request, such as an appeal, extension, reconsideration, or cancellation.

The Response to a Request for Review communicates the status of the Request for Review – for example, certified in total, certified in part, not certified, pended – and provides specific information about the services that have been authorized.  The Response to a Request for Review can also be used to request additional information, such as supporting documentation, relating to the review.  For information on responding to a request for supporting documentation click here.

Another use of the Health Care Services Request for Review is to submit or cancel a medical services reservation, which is required by some health plans when a limited number of a particular service or procedure is allowed.  Approval of the service reservation deducts from the total allowable number of that service or procedure.

  • Referral / Prior Authorization

    • Standards

       Current Standard

      The current mandated version of the Health Care Services Review – Request for Review and Response (278) is 5010.

      The Technical Report Type 3 ASC X12N/005010X217 Health Care Services Review – Request for Review and Response (278) can be purchased at the ASC X12 Store.

      Anticipated Standard

      The next anticipated version of the Health Care Services Review – Request for Review and Response (278) is 7030™. This TR3 will be available for public review and comment from September 1, 2017 through January 31, 2018.

      Online ASC X12 Public Review Forum

    • Companion Guide

    • Operating Rules

      Regulation

      Although CAQH CORE® has developed operating rules pertaining to the ASC X12N Health Care Services Review – Request for Review and Response (278) for their voluntary Phase IV certification program, the National Committee on Vital and Health Statistics (NCVHS), advisory body to the Department of Health and Human Services, recommended that the Phase IV Operating Rules not be adopted under regulatory mandate. No federal regulation is anticipated.

      Voluntary Certification

      CAQH CORE offers a voluntary certification program for their Phase IV Operating Rules, which cover the ASC X12N Health Care Services Review – Request for Review and Response (278) transaction.

      Claims and Encounters / Health Plan Enrollment / Health Plan Premium Payment / Referral and Authorization Operating Rules