Referral / Prior 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). 

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. 


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.

Standards

Current Version

The current industry version of the Health Care Services Review – Request for Review and Response (278) is 5010. This version was adopted under HIPAA to replace version 4010 on January 16, 2009.

View the Regulation

The Technical Report Type 3 ASC X12N/005010X217 Health Care Services Review – Request for Review and Response (278) can be purchased at the www.x12.org/products.

Next Published Version

The next published version of the ASC X12N Health Care Services Review – Request for Review and Response (278) transaction will be 7030™.

See the Change Healthcare Regulatory and Standards Quarterly Update for details concerning the X12 publication schedule. 

Anticipated Regulation

Immediately following publication of 7030TM, X12 will promote the TR3 to version 8010 TM and is expected to recommend the 8010 TM version to CMS for adoption under HIPAA.

Note: Following the publication of version 8010, X12 will move to an annual release cycle of TR3s.  See https://x12.org/about/arc-faq for more information.

7030TM and 8010TM are trademarks of X12.  All rights reserved.