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6.4.8 IN3 - insurance additional information, certification segment

The IN3 segment contains additional insurance information for certifying the need for patient care. Fields used by this segment are defined by HCFA, or other regulatory agencies.

Figure 6-8. IN3 attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

4

SI

R



00502

Set ID - IN3

2

59

CX

O



00503

Certification Number

3

60

XCN

O

Y


00504

Certified By

4

1

ID

O


0136

00505

Certification Required

5

10

CM

O


0148

00506

Penalty

6

26

TS

O



00507

Certification Date/Time

7

26

TS

O



00508

Certification Modify Date/Time

8

60

XCN

O

Y


00509

Operator

9

8

DT

O



00510

Certification Begin Date

10

8

DT

O



00511

Certification End Date

11

3

CM

O


0149

00512

Days

12

60

CE

O


0233

00513

Non-Concur Code/Description

13

26

TS

O



00514

Non-Concur Effective Date/Time

14

60

XCN

O

Y


00515

Physician Reviewer

15

48

ST

O



00516

Certification Contact

16

40

XTN

O

Y


00517

Certification Contact Phone Number

17

60

CE

O



00518

Appeal Reason

18

60

CE

O



00519

Certification Agency

19

40

XTN

O

Y


00520

Certification Agency Phone Number

20

40

CM

O

Y


00521

Pre-Certification Req/Window

21

48

ST

O



00522

Case Manager

22

8

DT

O



00523

Second Opinion Date

23

1

IS

O


0151

00524

Second Opinion Status

24

1

IS

O

Y

0152

00525

Second Opinion Documentation Received

25

60

XCN

O

Y


00526

Second Opinion Physician

6.4.8.0 IN3 field definitions

6.4.8.1 Set ID - IN3 (SI) 00502

Definition: IN3-1-set ID contains the number that identifies this transaction. For the first occurrence of the segment the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.4.8.2 Certification number (CX) 00503

Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility (HD)

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the number assigned by the certification agency.

6.4.8.3 Certified by (XCN) 00504

Components: <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the party that approved the certification. Multiple names and identifiers for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this field are described in Chapter 2.

6.4.8.4 Certification required (ID) 00505

Definition: This field indicates whether certification is required. Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.8.5 Penalty (CM) 00506

Components: <penalty type (IS)> ^ <penalty amount (NM)>

Definition: This field contains the penalty, in dollars or a percentage, that will be assessed if the pre-certification is not performed. Refer to user-defined table 0148 - Penalty type for suggested values.

User-defined Table 0148 - Penalty type

Value

Description

AT

PC

Currency amount

Percentage

6.4.8.6 Certification date/time (TS) 00507

Definition: This field contains the date and time stamp that indicates when insurance was certified to exist for the patient.

6.4.8.7 Certification modify date/time (TS) 00508

Definition: This field contains the date/time that the certification was modified.

6.4.8.8 Operator (XCN) 00509

Components: <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the party that is responsible for sending this certification information. Multiple names for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this field are described in Chapter 2.

6.4.8.9 Certification begin date (DT) 00510

Definition: This field contains the date that this certification begins.

6.4.8.10 Certification end date (DT) 00511

Definition: This field contains date that this certification ends.

6.4.8.11 Days (CM) 00512

Components: <day type (IS)> ^ <number of days (NM)>

Definition: This field contains the number of days for which this certification is valid. This field applies to denied, pending, or approved days. Refer to user-defined table 0149 - Day type for suggested values.

User-defined Table 0149 - Day type

Value

Description

AP

Approved

DE

Denied

PE

Pending

6.4.8.12 Non-concur code/description (CE) 00513

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains the non-concur code and description for a denied request. Refer to user-defined table 0233 - Non-concur code/description for suggested values.

6.4.8.13 Non-concur effective date/time (TS) 00514

Definition: This field contains the effective date of the non-concurrence classification.

6.4.8.14 Physician reviewer (XCN) 00515

Components: <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the physician who works with and reviews cases that are pending physician review for the certification agency. Multiple names for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this field are described in Chapter 2.

6.4.8.15 Certification contact (ST) 00516

Definition: This field contains the name of the party contacted at the certification agency who granted the certification and communicated the certification number.

6.4.8.16 Certification contact phone number (XTN) 00517

Components: [NNN] [(999)]999-9999 [X99999] [B99999] [C any text] ^<telecommunication use code (ID)> ^ <telecommunication equipment type (ID)>^ <email address (ST)> ^ <country code (NM)> ^ <area/city code (NM)> ^ <phone number (NM)> ^ <extension (NM)> ^ <any text (ST)>

Definition: This field contains the phone number of the certification contact. Multiple phone numbers for the same certification contact may be sent in this sequence. The primary phone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition. The components of this field are described in Chapter 2.

6.4.8.17 Appeal reason (CE) 00518

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains the reason that an appeal was made on a non-concur for certification.

6.4.8.18 Certification agency (CE) 00519

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains the certification agency.

6.4.8.19 Certification agency phone number (XTN) 00520

Components: [NNN] [(999)]999-9999 [X99999] [B99999] [C any text] ^<telecommunication use code (ID)> ^ <telecommunication equipment type (ID)>^ <email address (ST)> ^ <country code (NM)> ^ <area/city code (NM)> ^ <phone number (NM)> ^ <extension (NM)> ^ <any text (ST)>

Definition: This field contains the phone number of the certification agency. The components of this field are described in Chapter 2.

6.4.8.20 Pre-certification req/window (CM) 00521

Components: <pre-certification patient type (IS)> ^ <pre-certification required (ID)> ^ <pre-certification window (TS)>

Definition: This field indicates whether pre-certification is required for particular patient types, and the time window for obtaining the certification. The following components of this field are defined as follows:

pre-certification patient type refers to user-defined table 0150 - Pre-certification patient type for suggested values

pre-certification required refers to HL7 table 0136 - Yes/no indicator for valid values

pre-certification window is the amount of time required to attain certification from arrival at the institution. Its format follows the time stamp (TS) data type rules.

User-defined Table 0150 - Pre-certification patient type

Value

Description

ER

Emergency

IPE

Inpatient elective

OPE

Outpatient elective

UR

Urgent

6.4.8.21 Case manager (ST) 00522

Definition: This field contains the entity who/which is handling this particular patient’s case (e.g., UR nurse, or a specific facility location).

6.4.8.22 Second opinion date (DT) 00523

Definition: This field contains the date that the second opinion was obtained.

6.4.8.23 Second opinion status (IS) 00524

Definition: This field contains the code that represents the status of the second opinion. Refer to user-defined table 0151 - Second opinion status for suggested values.

6.4.8.24 Second opinion documentation received (IS) 00525

Definition: Use this field if accompanying documentation has been received by the provider. Refer to user-defined table 0152 - Second opinion documentation received for suggested values.

6.4.8.25 Second opinion practitioner (XCN) 00526

Components: <ID number (ST)> ^<family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains an identifier and name of the physician who provided the second opinion. Multiple names and identifiers for the same person may be sent in this sequence. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this field are described in Chapter 2.

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