A Deeper Dive into the 278 Transaction: A Referral & Authorization Request

By Faride Beaubien,

We have previously walked through what goes on behind eligibility and benefit requests or 270/271 transactions, when a patient visits his or her primary care physician (PCP). We will now discuss the 278 transaction: a referral and authorization request.

This transaction set is generally used as a ‘next step’ following an appointment with a physician. The doctor will submit a 278 (via a practice management system) to the member’s insurance company to notify them of the following:

  • Scheduled inpatient or specialty care
  • Patient arrival or discharge from a facility
  • Health services information sent to service providers
  • Changes to previously sent information

For instance, if a patient is experiencing eye pain, he or she would first consult a PCP- who will then determine if that patient needed specialty care outside their scope. They would then request a referral to an ophthalmologist. This referral doesn’t just happen on a piece of paper; it is an electronic request… and response! The doctor, or the doctor’s office as the case may be, is asking a health insurance company to authorize the patient to receive specialty care. Since specialty care is generally more costly than preventative care, the health insurance company reviews the patients medical history and benefit summary to determine if the specialty care is indeed required or necessary.

In addition, if that patient then goes on to require eye surgery, the ophthalmologist will submit another 278 (this time, a request) to not only authorize the procedure/specialty care, but also to notify them of date of surgery, facility and any other pertinent information. In response to the physician request, the health insurance company will return a 278 with an authorization or referral number. This number is then included in the claim submitted by the physician to the health insurance company for payment.

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These transactions link consumers, providers, and health insurance companies; allowing PokitDok to create the most comprehensive and transparent view of these interactions. The 278 transaction also helps reduce administrative costs through automation, thereby enabling provider offices to be more productive and increase data accuracy. As we move towards a more efficient electronic data interchange (EDI) system with the help of PokitDok’s X12 APIs, we’ll continue to leave phone calls, faxes and paper referrals in the past in favor of a more efficient, streamlined healthcare process.

 

The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

About Faride Beaubien

Faride is a technical and administrative professional with over 10 years experience in healthcare, real estate, private equity and technology. She is known for being a challenge seeker, problem solver & getting stuff done.

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The opinions expressed in this blog are of the authors and not of PokitDok's. The posts on this blog are for information only, and are not intended to substitute for a doctor-patient or other healthcare professional-patient relationship nor do they constitute medical or healthcare advice.

  Tags: Dev, Enterprise, Provider

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  Comments: 1

  1. Elias Elizondo


    I would love the see this process in action, the current system takes too long.

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