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.