ASC X12N 005010X217 Health Care Services Review Request for Review and Response
The 278 implementation guide defines request and response transactions for admission certification, referrals, service certification, extensions, appeals, reservations, and cancellations between providers, utilization-management organizations, and intermediaries.
What the authority record establishes
The 278 implementation guide defines request and response transactions for admission certification, referrals, service certification, extensions, appeals, reservations, and cancellations between providers, utilization-management organizations, and intermediaries.
Required for applicable HIPAA electronic health care services review transactions, subject to current HHS enforcement policy and exceptions
The exact official title, issuing body, jurisdiction, version or application record, and linked source define the scope of this page. Readers should not transfer the authority's status to a commercial product or infer transaction-, patient-, system-, site-, or organization-specific applicability from this summary.
Why it matters to this market
Most current electronic medical-service prior authorization environments must account for the HIPAA transaction baseline even as CMS and Da Vinci workflows accelerate FHIR adoption. A credible architecture explains whether and where translation, enforcement discretion, or direct FHIR exchange applies.
Affected operating stages
- Request Submission
- Status Inquiry
- Determination Response
- Extension Or Revision
- Appeal Review
- Cancellation
Capabilities to examine
Medical-Service Electronic Submission
Ask how the system or service identifies the controlling source and version, applies customer-specific interpretation, handles exceptions, preserves human judgment, and retains evidence for medical-service electronic submission.
Authorization Status Tracking
Ask how the system or service identifies the controlling source and version, applies customer-specific interpretation, handles exceptions, preserves human judgment, and retains evidence for authorization status tracking.
Appeals And Peer-To-Peer Workflow
Ask how the system or service identifies the controlling source and version, applies customer-specific interpretation, handles exceptions, preserves human judgment, and retains evidence for appeals and peer-to-peer workflow.
X12 278 And Attachment Exchange
Ask how the system or service identifies the controlling source and version, applies customer-specific interpretation, handles exceptions, preserves human judgment, and retains evidence for X12 278 and attachment exchange.
Audit Trail And Decision Provenance
Ask how the system or service identifies the controlling source and version, applies customer-specific interpretation, handles exceptions, preserves human judgment, and retains evidence for audit trail and decision provenance.
Affected buyer audiences
- providers and health plans
- utilization-management organizations
- clearinghouses
- EDI and FHIR interoperability vendors
- HIPAA transaction compliance teams
Implementation questions
- Which entities, products, populations, transactions, systems, sites, or jurisdictions are actually within scope?
- What is binding, what is guidance, and what is a technical or consensus standard?
- Which publication, adoption, effective, application, transition, and enforcement dates differ?
- Who owns legal, clinical, quality, regulatory, policy, or operational interpretation?
- How will a source revision affect open work and historical decisions?
Interpretation boundary
Prior Auth Monitor does not provide patient-specific medical advice, determine coverage, authorize care, or establish final payment. Its records support organizational research and operating review.