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 CMS, or other regulatory agencies.

HL7 Attribute Table - IN3 - Insurance Additional Information, Certification Segment

Seq#	Data Element Name	DataType	Usage	Vocabulary	Cardinality	Item #	Length	C.LEN	Flags
IN3
1	Set ID - IN3	SI	R		[1..1]	00502	[1..4]
2	Certification Number	CX	O		[0..1]	00503
3	Certified By	XCN	O		[0..*]	00504
4	Certification Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	00505	[1..1]
5	Penalty	MOP	O		[0..1]	00506
6	Certification Date/Time	DTM	O		[0..1]	00507
7	Certification Modify Date/Time	DTM	O		[0..1]	00508
8	Operator	XCN	O		[0..*]	00509
9	Certification Begin Date	DT	O		[0..1]	00510
10	Certification End Date	DT	O		[0..1]	00511
11	Days	DTN	O		[0..1]	00512
12	Non-Concur Code/Description	CWE	O	0233 Non-Concur Code/Description	[0..1]	00513
13	Non-Concur Effective Date/Time	DTM	O		[0..1]	00514
14	Physician Reviewer	XCN	O	0010 Physician ID	[0..*]	00515
15	Certification Contact	ST	O		[0..1]	00516		48	#
16	Certification Contact Phone Number	XTN	O		[0..*]	00517
17	Appeal Reason	CWE	O	0345 Appeal Reason	[0..1]	00518
18	Certification Agency	CWE	O	0346 Certification Agency	[0..1]	00519
19	Certification Agency Phone Number	XTN	O		[0..*]	00520
20	Pre-Certification Requirement	ICD	O	0136(R) Yes/no Indicator(Required)	[0..*]	00521
21	Case Manager	ST	O		[0..1]	00522		48	#
22	Second Opinion Date	DT	O		[0..1]	00523
23	Second Opinion Status	CWE	O	0151 Second Opinion Status	[0..1]	00524
24	Second Opinion Documentation Received	CWE	O	0152 Second Opinion Documentation Received	[0..*]	00525
25	Second Opinion Physician	XCN	O	0010 Physician ID	[0..*]	00526
26	Certification Type	CWE	O	0921 Certification Type Code	[0..1]	03336
27	Certification Category	CWE	O	0922 Certification Category Code	[0..1]	03337
28	Online Verification Date/Time	DTM	O		[0..1]	02483
29	Online Verification Result	CWE	C	0970(S) Online Verification Result(Suggested)		02484
30	Online Verification Result Error Code	CWE	C	0971(S) Online Verification Result Error Code(Suggested)		02485
31	Online Verification Result Check Digit	ST	C			02486

IN3-1: Set ID - IN3 (SI) 00502

Definition: IN3-1 - Set ID - IN3 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. The set ID in the IN3 segment is used when there are multiple certifications for the insurance plan identified in IN1-2.

IN3-2: Certification Number (CX) 00503

Definition: This field contains the number assigned by the certification agency. The assigning authority and identifier type code are strongly recommended for all CX data types.

IN3-3: Certified By (XCN) 00504

Definition: This field contains the party that approved the certification. Multiple names and identifiers for the same person may be sent in this sequence Specification of meaning based on sequence is deprecated.

IN3-4: Certification Required (ID) 00505

Definition: This field indicates whether certification is required. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

• Y    certification required

• N    certification not required

IN3-5: Penalty (MOP) 00506

Definition: This field contains the penalty, in dollars or a percentage that will be assessed if the pre-certification is not performed.

IN3-6: Certification Date/Time (DTM) 00507

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

IN3-7: Certification Modify Date/Time (DTM) 00508

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

IN3-8: Operator (XCN) 00509

Definition: This field contains the name party who is responsible for sending this certification information. Multiple names for the same person may be sent in this sequence. Specification of meaning based on sequence is deprecated.

IN3-9: Certification Begin Date (DT) 00510

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

IN3-10: Certification End Date (DT) 00511

Definition: This field contains date that this certification ends.

IN3-11: Days (DTN) 00512

Definition: This field contains the number of days for which this certification is valid. This field applies to denied, pending, or approved days.

IN3-12: Non-Concur Code/Description (CWE) 00513

Definition: This field contains the non-concur code and description for a denied request. Refer to User-defined Table 0233 - Non-Concur Code/Description in Chapter 2C, Code Tables, for suggested values.

IN3-13: Non-Concur Effective Date/Time (DTM) 00514

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

IN3-14: Physician Reviewer (XCN) 00515

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. Specification of meaning based on sequence is deprecated. Refer to User-defined Table 0010 - Physician ID in Chapter 2C, Code Tables, for suggested values.

IN3-15: 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.

IN3-16: Certification Contact Phone Number (XTN) 00517

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. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

IN3-17: Appeal Reason (CWE) 00518

Definition: This field contains the reason that an appeal was made on a non-concur for certification. Refer to User-defined Table 0345 - Appeal Reason in Chapter 2C, Code Tables, for suggested values.

IN3-18: Certification Agency (CWE) 00519

Definition: This field contains the certification agency. Refer to User-defined Table 0346 - Certification Agency in Chapter 2C, Code Tables, for suggested values.

IN3-19: Certification Agency Phone Number (XTN) 00520

Definition: This field contains the phone number of the certification agency.

IN3-20: Pre-Certification Requirement (ICD) 00521

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 required refers to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

• Y    pre-certification required

• N    no pre-certification required

• pre-certification window is the date/time by which the pre-certification must be obtained.

IN3-21: Case Manager (ST) 00522

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

IN3-22: Second Opinion Date (DT) 00523

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

IN3-23: Second Opinion Status (CWE) 00524

Definition: This field contains the code that represents the status of the second opinion. Refer to User-defined Table 0151 - Second Opinion Status in Chapter 2C, Code Tables, for suggested values.

IN3-24: Second Opinion Documentation Received (CWE) 00525

Definition: Use this field if accompanying documentation has been received by the provider. Refer to User-defined Table 0152 - Second Opinion Documentation Receivedin Chapter 2C, Code Tables,for suggested values.

IN3-25: Second Opinion Physician (XCN) 00526

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. Specification of meaning based on sequence is deprecated. Refer to User-defined Table 0010 - Physician ID in Chapter 2C, Code Tables, for suggested values.

IN3-26: Certification Type (CWE) 03336

Definition: This field contains the certification type code for a specific certification. Refer to User-defined Table 0921 – Certification Type Code in Chapter 2C, Code Tables, for suggested values.

IN3-27: Certification Category (CWE) 03337

Definition: This field contains the certification category code for a specific certification. Refer to User-defined Table 0922 – Certification Category Code in Chapter 2C, Code Tables, for suggested values.

IN3-28: Online Verification Date/Time (DTM) 02483

Definition: This field contains the timestamp of the online verification of the insurance information.

IN3-29: Online Verification Result (CWE) 02484

Definition: This field contains the result of the online verification. Refer to User-defined Table 0970 – Online Verification Result in Chapter 2C, Code Tables, for suggested values. This field is required if IN3-28 is populated.

IN3-30: Online Verification Result Error Code (CWE) 02485

Definition: This field contains the error code for the result of the online verification. Refer to User-defined Table 0791 – Online Verification Result Error Code in Chapter 2C, Code Tables, for suggested values. This field is required if IN3-28 is populated and an error status is returned.

IN3-31: Online Verification Result Check Digit (ST) 02486

Definition: This field contains the check digit for the online verification of the insurance information. This field is required if IN3-28 is populated.