GLOBAL MAP DATA DICTIONARY #356.22 -- HCS REVIEW TRANSMISSION FILE 6/27/25 PAGE 1
STORED IN ^IBT(356.22, *** NO DATA STORED YET *** SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 2.0)
-----------------------------------------------------------------------------------------------------------------------------------
This file contains information related to Healthcare Services Review worklist and corresponding HL7 messages (message type 278).
CROSS
REFERENCED BY: TRANSMISSION DATE/TIME(AC), DATE ENTERED(B), MESSAGE CONTROL ID(C), DATE MANUALLY REMOVED(F)
INDEXED BY: STATUS & DATE ENTERED (AD), PATIENT & EVENT DATE (D), INPATIENT / OUTPATIENT & INSURANCE POLICY & SOURCE & PATIENT
(E)
^IBT(356.22,D0,0)= (#.01) DATE ENTERED [1D] ^ (#.02) PATIENT [2P:2] ^ (#.03) INSURANCE POLICY [3N] ^ (#.04) INPATIENT /
==>OUTPATIENT [4S] ^ (#.05) WARD [5P:42] ^ (#.06) CLINIC [6P:44] ^ (#.07) EVENT DATE [7F] ^ (#.08) STATUS [8S] ^
==>(#.09) MARKED 'IN PROGRESS' BY [9P:200] ^ (#.1) DATE MARKED 'IN PROGRESS' [10D] ^ (#.11) REQUESTED BY
==>[11P:200] ^ (#.12) MESSAGE CONTROL ID [12F] ^ (#.13) INQUIRY [13P:356.22] ^ (#.14) RESPONSE [14P:356.22] ^
==>(#.15) TRANSMISSION DATE/TIME [15D] ^ (#.16) SOURCE [16D] ^ (#.17) TICKLER [17F] ^ (#.18) FROM RESPONSE [18N]
==>^ (#.19) 215 TRIGGERED [19S] ^ (#.2) TRANSACTION TYPE [20S] ^ (#.21) RESPONSE STATUS [21S] ^ (#.22) DELETED
==>RESPONSE [22S] ^ (#.23) DATE MANUALLY REMOVED [23D] ^ (#.24) MANUALLY REMOVED BY [24P:200] ^ (#.25) DELETE
==>REASON [25P:356.023] ^ (#.26) MANUAL 215 [26S] ^ (#.27) REQ FROM RESP [27S] ^
^IBT(356.22,D0,1,0)=^356.221DA^^ (#1) COMMENTS
^IBT(356.22,D0,1,D1,0)= (#.01) DATE ENTERED [1D] ^ (#.02) ENTERED BY [2P:200] ^
^IBT(356.22,D0,1,D1,1,0)=^356.231^^ (#.03) COMMENT
^IBT(356.22,D0,1,D1,1,D2,0)= (#.01) COMMENT [1W] ^
^IBT(356.22,D0,2)= (#2.01) REQUEST CATEGORY [1P:356.001] ^ (#2.02) CERTIFICATION TYPE CODE [2P:356.002] ^ (#2.03) SERVICE TYPE
==>CODE [3P:365.013] ^ (#2.04) FACILITY TYPE QUALIFIER [4S] ^ (#2.05) FACILITY TYPE [5P:353.1] ^ (#2.06) LOCATION
==>OF CARE [6S] ^ (#2.07) BILL CLASSIFICATION [7S] ^ (#2.08) RELATED CAUSES #1 [8S] ^ (#2.09) RELATED CAUSES #2
==>[9S] ^ (#2.1) RELATED CAUSES #3 [10S] ^ (#2.11) STATE [11P:5] ^ (#2.12) COUNTRY [12P:779.004] ^ (#2.13) LEVEL
==>OF SERVICE [13S] ^ (#2.14) CURRENT HEALTH CONDITION [14P:356.003] ^ (#2.15) PROGNOSIS CODE [15P:356.004] ^
==>(#2.16) RELEASE OF INFORMATION CODE [16S] ^ (#2.17) DELAY REASON [17P:356.005] ^ (#2.18) ACCIDENT DATE [18D] ^
==>(#2.19) LAST MENSTRUAL PERIOD DATE [19D] ^ (#2.2) ESTIMATED DOB [20D] ^ (#2.21) ILLNESS DATE [21D] ^ (#2.22)
==>DISCHARGE DATE [22D] ^ (#2.23) CERTIFICATION ISSUE DATE [23D] ^ (#2.24) CERTIFICATION EXPIRATION DATE [24D] ^
==>(#2.25) CERTIFICATION EFFECTIVE DATE [25D] ^ (#2.26) CERT EFFECTIVE THRU DATE [26D] ^
^IBT(356.22,D0,3,0)=^356.223PA^^ (#3) PATIENT DIAGNOSIS
^IBT(356.22,D0,3,D1,0)= (#.01) DIAGNOSIS TYPE [1P:356.006] ^ (#.02) DIAGNOSIS CODE [2V] ^ (#.03) DIAGNOSIS DATE [3D] ^
^IBT(356.22,D0,4)= (#4.01) HCSD QUANTITY QUALIFIER [1P:365.016] ^ (#4.02) HCSD SERVICE UNIT COUNT [2N] ^ (#4.03) HCSD UNITS OF
==>MEASUREMENT [3S] ^ (#4.04) HCSD SAMPLE SELECTION MODULUS [4N] ^ (#4.05) HCSD TIME PERIOD QUALIFIER
==>[5P:365.015] ^ (#4.06) HCSD PERIOD COUNT [6N] ^ (#4.07) HCSD DELIVERY FREQUENCY [7P:365.025] ^ (#4.08) HCSD
==>DELIVERY TIME PATTERN [8P:356.007] ^ (#4.09) AMBULANCE CERT. CONDITION [9S] ^ (#4.1) AMBULANCE CONDITION #1
==>[10P:356.008] ^ (#4.11) AMBULANCE CONDITION #2 [11P:356.008] ^ (#4.12) AMBULANCE CONDITION #3 [12P:356.008] ^
==>(#4.13) AMBULANCE CONDITION #4 [13P:356.008] ^ (#4.14) AMBULANCE CONDITION #5 [14P:356.008] ^
^IBT(356.22,D0,5)= (#5.01) CHIROPRACTIC CERT. CONDITION [1S] ^ (#5.02) CHIROPRACTIC CONDITION #1 [2P:356.008] ^ (#5.03)
==>CHIROPRACTIC CONDITION #2 [3P:356.008] ^ (#5.04) CHIROPRACTIC CONDITION #3 [4P:356.008] ^ (#5.05) CHIROPRACTIC
==>CONDITION #4 [5P:356.008] ^ (#5.06) CHIROPRACTIC CONDITION #5 [6P:356.008] ^ (#5.07) DME CERT. CONDITION [7S]
==>^ (#5.08) DME CONDITION #1 [8P:356.008] ^ (#5.09) DME CONDITION #2 [9P:356.008] ^ (#5.1) DME CONDITION #3
==>[10P:356.008] ^ (#5.11) DME CONDITION #4 [11P:356.008] ^ (#5.12) DME CONDITION #5 [12P:356.008] ^ (#5.13)
==>OXYGEN CERT. CONDITION [13S] ^ (#5.14) OXYGEN CONDITION #1 [14P:356.008] ^ (#5.15) OXYGEN CONDITION #2
==>[15P:356.008] ^ (#5.16) OXYGEN CONDITION #3 [16P:356.008] ^ (#5.17) OXYGEN CONDITION #4 [17P:356.008] ^
==>(#5.18) OXYGEN CONDITION #5 [18P:356.008] ^
^IBT(356.22,D0,6)= (#6.01) FUNCT. LIMIT CERT. CONDITION [1S] ^ (#6.02) FUNCT. LIMIT CONDITION #1 [2P:356.008] ^ (#6.03) FUNCT.
==>LIMIT CONDITION #2 [3P:356.008] ^ (#6.04) FUNCT. LIMIT CONDITION #3 [4P:356.008] ^ (#6.05) FUNCT. LIMIT
==>CONDITION #4 [5P:356.008] ^ (#6.06) FUNCT. LIMIT CONDITION #5 [6P:356.008] ^ (#6.07) ACTIVITIES CERT.
==>CONDITION [7S] ^ (#6.08) ACTIVITIES CONDITION #1 [8P:356.008] ^ (#6.09) ACTIVITIES CONDITION #2 [9P:356.008] ^
==>(#6.1) ACTIVITIES CONDITION #3 [10P:356.008] ^ (#6.11) ACTIVITIES CONDITION #4 [11P:356.008] ^ (#6.12)
==>ACTIVITIES CONDITION #5 [12P:356.008] ^ (#6.13) MENTAL STATUS CERT. CONDITION [13S] ^ (#6.14) MENTAL STATUS
==>CONDITION #1 [14P:356.008] ^ (#6.15) MENTAL STATUS CONDITION #2 [15P:356.008] ^ (#6.16) MENTAL STATUS
==>CONDITION #3 [16P:356.008] ^ (#6.17) MENTAL STATUS CONDITION #4 [17P:356.008] ^ (#6.18) MENTAL STATUS
==>CONDITION #5 [18P:356.008] ^
^IBT(356.22,D0,7)= (#7.01) ADMISSION TYPE [1S] ^ (#7.02) ADMISSION SOURCE [2P:356.009] ^ (#7.03) PATIENT STATUS [3P:356.01] ^
==>(#7.04) NURSING HOME STATUS [4P:356.011] ^ (#7.05) TREATMENT SERIES NUMBER [5N] ^ (#7.06) TREATMENT COUNT [6N]
==>^ (#7.07) SUBLUXATION LEVEL CODE #1 [7P:356.012] ^ (#7.08) SUBLUXATION LEVEL CODE #2 [8P:356.012] ^ (#7.09)
==>PATIENT CONDITION CODE [9S] ^ (#7.1) COMPLICATION INDICATOR [10S] ^ (#7.11) PAT. COND. DESCRIPTION LINE 1
==>[11F] ^ (#7.12) PAT. COND. DESCRIPTION LINE 2 [12F] ^ (#7.13) X-RAY AVAILABLE? [13S] ^
^IBT(356.22,D0,8)= (#8.01) OXYGEN EQUIPMENT TYPE #1 [1P:356.013] ^ (#8.02) OXYGEN EQUIPMENT TYPE #2 [2P:356.013] ^ (#8.03) OXYGEN
==>EQUIPMENT TYPE #3 [3P:356.013] ^ (#8.04) OXYGEN EQUIPMENT REASON [4F] ^ (#8.05) OXYGEN FLOW RATE [5N] ^
==>(#8.06) DAILY OXYGEN USE COUNT [6N] ^ (#8.07) OXYGEN USE PERIOD HOUR COUNT [7N] ^ (#8.08) RESPIRATORY
==>THERAPIST ORDER [8F] ^
^IBT(356.22,D0,9)= (#9.01) ARTERIAL BLOOD GAS QUANTITY [1N] ^ (#9.02) OXYGEN SATURATION QUANTITY [2N] ^ (#9.03) OXYGEN TEST
==>CONDITION [3P:356.014] ^ (#9.04) OXYGEN TEST FINDINGS #1 [4P:356.015] ^ (#9.05) OXYGEN TEST FINDINGS #2
==>[5P:356.015] ^ (#9.06) OXYGEN TEST FINDINGS #3 [6P:356.015] ^ (#9.07) PORTABLE OXYGEN SYSTEM FLOW [7N] ^
==>(#9.08) OXYGEN DELIVERY SYSTEM [8P:356.016] ^
^IBT(356.22,D0,10)= (#10.01) HOME HEALTH START DATE [1D] ^ (#10.02) HOME HEALTH CERT. START [2D] ^ (#10.03) HOME HEALTH CERT. END
==>[3D] ^ (#10.04) COVERED BY MEDICARE? [4S] ^ (#10.05) SURGERY DATE [5D] ^ (#10.06) SURGICAL PROCEDURE CODE
==>TYPE [6S] ^ (#10.07) SURGICAL PROCEDURE CODE [7V] ^ (#10.08) PHYSICIAN ORDER DATE [8D] ^ (#10.09) LAST VISIT
==>DATE [9D] ^ (#10.1) PHYSICIAN CONTACT DATE [10D] ^ (#10.11) LAST ADMISSION START DATE [11D] ^ (#10.12) LAST
==>ADMISSION END DATE [12D] ^ (#10.13) PATIENT LOCATION [13P:356.017] ^
^IBT(356.22,D0,11,0)=^356.2211PA^^ (#11) ATTACHMENTS
^IBT(356.22,D0,11,D1,0)= (#.01) REPORT TYPE CODE [1P:356.018] ^ (#.02) REPORT TRANSMISSION CODE [2S] ^ (#.03) ATTACHMENT CONTROL
==>NUMBER [3F] ^ (#.04) ATTACHMENT DESCRIPTION [4F] ^
^IBT(356.22,D0,12,0)=^356.2212^^ (#12) MESSAGE TEXT
^IBT(356.22,D0,12,D1,0)= (#.01) MESSAGE TEXT [1W] ^
^IBT(356.22,D0,13,0)=^356.2213PA^^ (#13) PATIENT EVENT PROVIDER
^IBT(356.22,D0,13,D1,0)= (#.01) PROVIDER TYPE [1P:365.022] ^ (#.02) PERSON / NON-PERSON [2S] ^ (#.03) PROVIDER [3V] ^ (#.04) PER
==>LOOP IDENTIFIER [4P:365.027] ^ (#.05) CONTACT FUNCTION CODE [5F] ^ (#.06) CONTACT NAME [6F] ^ (#.07)
==>COMMUNICATION NO. QUALIFIER-1 [7P:365.021] ^ (#.08) COMMUNICATION NO. QUALIFIER-2 [8P:365.021] ^ (#.09)
==>COMMUNICATION NO. QUALIFIER-3 [9P:365.021] ^
^IBT(356.22,D0,13,D1,1)= (#1) CONTACT COMMUNICATION NUMBER-1 [1F] ^
^IBT(356.22,D0,13,D1,2)= (#2) CONTACT COMMUNICATION NUMBER-2 [1F] ^
^IBT(356.22,D0,13,D1,3)= (#3) CONTACT COMMUNICATION NUMBER-3 [1F] ^
^IBT(356.22,D0,13,D1,4)= (#4.01) NM1 LOOP IDENTIFIER [1P:365.027] ^ (#4.02) ENTITY IDENTIFIER CODE [2P:365.022] ^ (#4.03) ENTITY
==>TYPE QUALIFIER [3S] ^ (#4.04) CONTACT LAST OR COMPANY NAME [4F] ^ (#4.05) CONTACT FIRST NAME [5F] ^
==>(#4.06) CONTACT MIDDLE NAME [6F] ^ (#4.07) CONTACT NAME SUFFIX [7F] ^ (#4.08) IDENTIFICATION CODE
==>QUALIFIER [8P:365.023] ^ (#4.09) IDENTIFICATION CODE [9F] ^
^IBT(356.22,D0,13,D1,5)= (#5) CONTACT ADDRESS LINE-1 [1F] ^ (#5.01) CONTACT ADDRESS LINE-2 [2F] ^ (#5.02) CONTACT CITY NAME [3F]
==>^ (#5.03) CONTACT STATE OR PROVINCE [4P:5] ^ (#5.04) CONTACT ZIP CODE [5F] ^ (#5.05) CONTACT COUNTRY
==>CODE [6P:779.004] ^ (#5.06) CONTACT COUNTRY SUBDIVISION [7F] ^
^IBT(356.22,D0,14,0)=^356.2214SA^^ (#14) PATIENT EVENT TRANSPORT
^IBT(356.22,D0,14,D1,0)= (#.01) LOCATION TYPE [1S] ^ (#.02) LOCATION NAME [2F] ^ (#.03) ADDRESS LINE 1 [3F] ^ (#.04) ADDRESS LINE
==>2 [4F] ^ (#.05) CITY [5F] ^ (#.06) STATE / PROVINCE [6P:5] ^ (#.07) ZIP / POSTAL CODE [7F] ^
^IBT(356.22,D0,15,0)=^356.2215SA^^ (#15) OTHER UMO
^IBT(356.22,D0,15,D1,0)= (#.01) UMO TYPE [1S] ^ (#.02) UMO NAME [2P:36] ^ (#.03) UMO DENIAL REASON #1 [3P:356.021] ^ (#.04) UMO
==>DENIAL REASON #2 [4P:356.021] ^ (#.05) UMO DENIAL REASON #3 [5P:356.021] ^ (#.06) UMO DENIAL REASON #4
==>[6P:356.021] ^ (#.07) UMO DENIAL DATE [7D] ^
^IBT(356.22,D0,16,0)=^356.2216A^^ (#16) SERVICE LINE
^IBT(356.22,D0,16,D1,0)= (#.01) SEQUENCE [1N] ^ (#.02) CERTIFICATION TYPE CODE [2P:356.002] ^ (#.03) SERVICE TYPE CODE
==>[3P:365.013] ^ (#.04) FACILITY TYPE QUALIFIER [4S] ^ (#.05) FACILITY TYPE [5P:353.1] ^ (#.06) LOCATION
==>OF CARE [6S] ^ (#.07) BILL CLASSIFICATION [7S] ^ (#.08) TRACE NUMBER [8F] ^ (#.09) TRACE ASSIGNING
==>ENTITY [9F] ^ (#.1) TRACE ASSIGNING ENTITY DESC. [10F] ^ (#.11) SERVICE DATE [11D] ^ (#.12)
==>CERTIFICATION ISSUE DATE [12D] ^ (#.13) CERTIFICATION EXPIRATION DATE [13D] ^ (#.14) CERTIFICATION
==>EFFECTIVE DATE [14D] ^ (#.15) REQUEST CATEGORY [15P:356.001] ^ (#.16) CERTIFICATION THRU DATE [16D] ^
==>(#.17) SERVICE THRU DATE [17D] ^
^IBT(356.22,D0,16,D1,1)= (#1.01) PROCEDURE CODE TYPE [1S] ^ (#1.02) PROCEDURE #1 [2V] ^ (#1.03) PROCEDURE CODE #2 [3V] ^ (#1.04)
==>PROCEDURE MODIFIER #1 [4P:81.3] ^ (#1.05) PROCEDURE MODIFIER #2 [5P:81.3] ^ (#1.06) PROCEDURE MODIFIER
==>#3 [6P:81.3] ^ (#1.07) PROCEDURE MODIFIER #4 [7P:81.3] ^ (#1.08) PROCEDURE DESCRIPTION [8F] ^ (#1.09)
==>SERVICE LINE AMOUNT [9N] ^ (#1.1) UNITS CODE [10S] ^ (#1.11) UNIT COUNT [11N] ^ (#1.12) SERVICE LINE
==>TYPE [12S] ^
^IBT(356.22,D0,16,D1,2)= (#2.01) DIAGNOSIS #1 [1S] ^ (#2.02) DIAGNOSIS #2 [2S] ^ (#2.03) DIAGNOSIS #3 [3S] ^ (#2.04) DIAGNOSIS #4
==>[4S] ^ (#2.05) EPSDT? [5S] ^ (#2.06) REVENUE CODE [6P:399.2] ^ (#2.07) RATE [7N] ^ (#2.08) NURSING HOME
==>STATUS [8P:356.011] ^ (#2.09) NURSING HOME LEVEL OF CARE [9P:356.019] ^
^IBT(356.22,D0,16,D1,3)= (#3.01) ORAL CAVITY DESIGNATION #1 [1S] ^ (#3.02) ORAL CAVITY DESIGNATION #2 [2S] ^ (#3.03) ORAL CAVITY
==>DESIGNATION #3 [3S] ^ (#3.04) ORAL CAVITY DESIGNATION #4 [4S] ^ (#3.05) ORAL CAVITY DESIGNATION #5 [5S]
==>^ (#3.06) PLACEMENT STATUS [6S] ^ (#3.07) DENTAL WORK DESCRIPTION [7F] ^
^IBT(356.22,D0,16,D1,4,0)=^356.22164PA^^ (#4) TOOTH INFORMATION
^IBT(356.22,D0,16,D1,4,D2,0)= (#.01) TOOTH CODE [1P:356.022] ^ (#.02) TOOTH SURFACE #1 [2S] ^ (#.03) TOOTH SURFACE #2 [3S] ^
==>(#.04) TOOTH SURFACE #3 [4S] ^ (#.05) TOOTH SURFACE #4 [5S] ^ (#.06) TOOTH SURFACE #5 [6S] ^
^IBT(356.22,D0,16,D1,5)= (#5.01) HCSD QUANTITY QUALIFIER [1P:365.016] ^ (#5.02) HCSD SERVICE UNIT COUNT [2N] ^ (#5.03) HCSD UNITS
==>OF MEASUREMENT [3S] ^ (#5.04) HCSD SAMPLE SELECTION MODULUS [4N] ^ (#5.05) HCSD TIME PERIOD QUALIFIER
==>[5P:365.015] ^ (#5.06) HCSD PERIOD COUNT [6N] ^ (#5.07) HCSD DELIVERY FREQUENCY [7P:365.025] ^ (#5.08)
==>HCSD DELIVERY TIME PATTERN [8P:356.007] ^
^IBT(356.22,D0,16,D1,6,0)=^356.22166PA^^ (#6) ATTACHMENTS
^IBT(356.22,D0,16,D1,6,D2,0)= (#.01) REPORT TYPE CODE [1P:356.018] ^ (#.02) REPORT TRANSMISSION CODE [2S] ^ (#.03) ATTACHMENT
==>CONTROL NUMBER [3F] ^ (#.04) ATTACHMENT DESCRIPTION [4F] ^
^IBT(356.22,D0,16,D1,7,0)=^356.22167^^ (#7) MESSAGE TEXT
^IBT(356.22,D0,16,D1,7,D2,0)= (#.01) MESSAGE TEXT [1W] ^
^IBT(356.22,D0,16,D1,8,0)=^356.22168PA^^ (#8) SERVICE PROVIDER
^IBT(356.22,D0,16,D1,8,D2,0)= (#.01) PROVIDER TYPE [1P:365.022] ^ (#.02) PERSON / NON-PERSON [2S] ^ (#.03) PROVIDER [3V] ^ (#.04)
==>PER LOOP IDENTIFIER [4P:365.027] ^ (#.05) CONTACT FUNCTION CODE [5F] ^ (#.06) CONTACT NAME [6F] ^
==>(#.07) COMMUNICATION NO. QUALIFIER-1 [7P:365.021] ^ (#.08) COMMUNICATION NO. QUALIFIER-2
==>[8P:365.021] ^ (#.09) COMMUNICATION NO. QUALIFIER-3 [9P:365.021] ^
^IBT(356.22,D0,16,D1,8,D2,1)= (#1) CONTACT COMMUNICATION NUMBER-1 [1F] ^
^IBT(356.22,D0,16,D1,8,D2,2)= (#2) CONTACT COMMUNICATION NUMBER-2 [1F] ^
^IBT(356.22,D0,16,D1,8,D2,3)= (#3) CONTACT COMMUNICATION NUMBER-3 [1F] ^
^IBT(356.22,D0,16,D1,8,D2,4)= (#4.01) NM1 LOOP IDENTIFIER [1P:365.027] ^ (#4.02) ENTITY IDENTIFIER CODE [2P:365.022] ^ (#4.03)
==>ENTITY TYPE QUALIFIER [3S] ^ (#4.04) CONTACT LAST OR COMPANY NAME [4F] ^ (#4.05) CONTACT FIRST NAME
==>[5F] ^ (#4.06) CONTACT MIDDLE NAME [6F] ^ (#4.07) CONTACT NAME SUFFIX [7F] ^ (#4.08) IDENTIFICATION
==>CODE QUALIFIER [8P:365.023] ^ (#4.09) IDENTIFICATION CODE [9F] ^
^IBT(356.22,D0,16,D1,8,D2,5)= (#5) CONTACT ADDRESS LINE-1 [1F] ^ (#5.01) CONTACT ADDRESS LINE-2 [2F] ^ (#5.02) CONTACT CITY NAME
==>[3F] ^ (#5.03) CONTACT STATE OR PROVINCE [4P:5] ^ (#5.04) CONTACT ZIP CODE [5F] ^ (#5.05) CONTACT
==>COUNTRY CODE [6P:779.004] ^ (#5.06) CONTACT COUNTRY SUBDIVISION [7F] ^
^IBT(356.22,D0,16,D1,9)= (#9.01) PREV. AUTHORIZATION # [1F] ^ (#9.02) PREV. ADMIN. REFERENCE # [2F] ^
^IBT(356.22,D0,16,D1,10,0)=^356.2316A^^ (#10) HI SEGMENTS
^IBT(356.22,D0,16,D1,10,D2,0)= (#.01) HI SEQUENCE [1N] ^ (#.02) CODE LIST QUALIFIER CODE [2P:356.006] ^ (#.03) INDUSTRY CODE [3F]
==>^ (#.04) DATE [4D] ^
^IBT(356.22,D0,16,D1,11)= (#11.01) CERTIFICATION ACTION CODE [1P:356.02] ^ (#11.02) REVIEW IDENTIFICATION NUMBER [2F] ^ (#11.03)
==>REVIEW DECISION REASON CODE [3P:356.021] ^ (#11.04) SECOND SURGICAL OPINION FLAG [4S] ^
^IBT(356.22,D0,16,D1,12)= (#12.01) NDC CODE #1 [1F] ^ (#12.02) NDC CODE #2 [2F] ^
^IBT(356.22,D0,17)= (#17.01) PREV. AUTHORIZATION # [1F] ^ (#17.02) PREV. ADMIN. REFERENCE # [2F] ^
^IBT(356.22,D0,18)= (#18.01) WEIGHT UNITS [1S] ^ (#18.02) PATIENT WEIGHT [2N] ^ (#18.03) AMBULANCE TRANSPORT CODE [3S] ^ (#18.04)
==>AMBULANCE TRANSPORT REASON [4S] ^ (#18.05) DISTANCE UNITS [5S] ^ (#18.06) TRANSPORT DISTANCE [6N] ^ ^ ^
==>(#18.09) ROUND TRIP PURPOSE DESCRIPTION [9F] ^ (#18.1) STRETCHER PURPOSE DESCRIPTION [10F] ^
^IBT(356.22,D0,19)= (#19) UMO CONTACT NAME [1F] ^ (#19.01) COMMUNICATION NO. QUALIFIER-1 [2P:365.021] ^ (#19.02) COMMUNICATION
==>NO. QUALIFIER-2 [3P:365.021] ^ (#19.03) COMMUNICATION NO. QUALIFIER-3 [4P:365.021] ^
^IBT(356.22,D0,20)= (#20) CONTACT COMMUNICATION NUMBER-1 [1F] ^
^IBT(356.22,D0,21)= (#21) CONTACT COMMUNICATION NUMBER-2 [1F] ^
^IBT(356.22,D0,22)= (#22) CONTACT COMMUNICATION NUMBER-3 [1F] ^
^IBT(356.22,D0,23,0)=^356.2223^^ (#23) DELETE REASON NOTE
^IBT(356.22,D0,23,D1,0)= (#.01) DELETE REASON NOTE [1W] ^
^IBT(356.22,D0,101,0)=^356.22101A^^ (#101) AAA SEGMENTS
^IBT(356.22,D0,101,D1,0)= (#.01) AAA SEQUENCE [1N] ^ (#.02) AAA LOOP IDENTIFIER [2P:365.027] ^ (#.03) VALID REQUEST INDICATOR
==>[3S] ^ (#.04) REJECT REASON CODE [4P:365.017] ^ (#.05) FOLLOW-UP ACTION CODE [5P:365.018] ^
^IBT(356.22,D0,101,D1,1)= (#1) FSC ERROR MESSAGE [1F] ^
^IBT(356.22,D0,103)= (#103.01) CERTIFICATION ACTION CODE [1P:356.02] ^ (#103.02) REVIEW IDENTIFICATION NUMBER [2F] ^ (#103.03)
==>REVIEW DECISION REASON CODE [3P:356.021] ^ (#103.04) SECOND SURGICAL OPINION FLAG [4S] ^
^IBT(356.22,D0,105,0)=^356.22105A^^ (#105) TRN SEGMENTS
^IBT(356.22,D0,105,D1,0)= (#.01) TRN SEQUENCE [1N] ^ (#.02) TRN LOOP IDENTIFIER [2P:365.027] ^ (#.03) TRACE TYPE CODE [3S] ^
==>(#.04) TRACE NUMBER [4F] ^ (#.05) TRACE ASSIGNING ENTITY ID [5F] ^ (#.06) TRACE ASSIGNING ENTITY ID-2
==>[6F] ^
^IBT(356.22,D0,107,0)=^356.22107A^^ (#107) HI SEGMENTS
^IBT(356.22,D0,107,D1,0)= (#.01) HI SEQUENCE [1N] ^ (#.02) CODE LIST QUALIFIER CODE [2P:356.006] ^ (#.03) INDUSTRY CODE [3F] ^
==>(#.04) DATE [4D] ^
INPUT TEMPLATE(S):
^DIE(1783)= IB ADD/EDIT 278
^DIE(1782)= IB CREATE 278 REQUEST
^DIE(1784)= IB CREATE 278 REQUEST SHORT
PRINT TEMPLATE(S):
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):