1. 278 REQUEST and RESPONSE Response (275) of additional info
Request (278) with or without additional
information (275)
REQUESTER
Provider
PCP
Specialist
Clinic or Group
Response with Request for additional information (278)
RESPONDENT
Payer
UMO
Response (275) of additional info
Response (278) of outcome
Sample Requests:
You can use 278 Request and Response alone, or in conjunction with the 275 Additional Patient Information
or a 278 Response containing a Request for Additional Information.
1. Request to refer a patient to a specialist (278) and its associated health care services review outcome response (278).
2. Request to pre-admit a patient to an institution (278) and its associated health care services review outcome response (278).
3. Request to authorize services (pre-certification) for a patient (278) and its associated health care services review outcome response (278)
4. Request for referral, pre-admission, or pre-certification (278) with additional patient condition information included (275) and its
associated health care services review response (278)
5. Request for health care services review (278) with pended response (278) with or without an associated request for additional
information to determine medical necessity.
The occurrence of either of the following (6 or 7) assumes the occurrence of one of the previous events.
6. Submission of requested additional patient condition information (275) and its follow-up response of the final health care services review
decision (278)
7. Request to change or modify an existing health care services review outcome (278) and its associated response (278)
* An outcome may be a final decision or a pended for review decision.