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.