PAInitiationRequest Elements

note refer to the schema for a complete list of fields, including details for painitiationresponse elements element code comments painitiationrequest note it is recommended to populate as many conditional elements as possible to maximize the prior authorization experience pareferenceid mandatory assigned by the prescribing system on the initial message and is used as a tracking identifier on all request and response prior authorization messages to tieback related prior authorization messages the identifier must be unique per prescribing system for at least 18 months note pareferenceid shall be established with the parequest when responding to a prior authorization renewal request (unsolicited painitiationresponse) papriorityindicator recommended indicates the requested pa processing priority if papriorityindicator is not populated, standard priority will be assumed values s standard priority x urgent/expedited priority note this value should be echoed on subsequent transactions the priority may also be changed on the parequest if the provider feels that the patient's health is at risk benefitscoordination note the fields below may be returned in the eligibility response (271) if a pbm/payer returns active coverage, these fields should be populated with the returned value please see sending prior authorization initiation requests docid\ f scglko2h5cdro le8w0 for more detail payeridentification conditional payerid conditional surescripts participant id assigned to the pbm/payer processoridentificationnumber conditional the pcn associated to the patient’s benefit iinnumber conditional the iin associated to the patient’s benefit mutuallydefined conditional the 271 message’s isa13 control number payername conditional pbm/payer name cardholderid conditional assigned cardholder id for the patient note pbm/payers may validate patients based on cardholder id cardholdername conditional cardholder name note pbm/payers may validate patients based on cardholder name groupid conditional id number identifying the health plan group groupname conditional name of the health plan group pbmmemberid conditional pbm/payer assigned member id for the patient patient note refer to the schema for a complete list of fields identification mandatory usage requirements if patient identification data exists, include the identification element and populate its child elements if no patient identification data is available, include the identification element but leave it empty (no child elements) socialsecurity conditional patient’s social security number not recommended to send unless explicitly required by a specific business or regulatory process genderandsex mandatory values m male f female u not specified or unknown n non binary an umbrella term for people with gender identities that fall somewhere outside of the traditional conceptions of strictly either female or male pregnancyindicator conditional code indicating the patient as pregnant or non pregnant address mandatory parent element for patient address information addressline1 mandatory patient’s primary address line city mandatory patient’s city stateprovince conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience postalcode conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience prescriber note the prescriber relates to the person requesting the prior authorization identification mandatory some pbm/payers may validate prescriber data against nppes or other prescriber directories using the fields under identification npi mandatory npi of the prescriber address mandatory parent element for patient address information addressline1 mandatory patient’s primary address line city mandatory patient’s city stateprovince conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience postalcode conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience medicationprescribed drugdescription mandatory drug name (full drug name, strength, and form) for a compound, the names of the ingredients in the compound or the prescriber’s preferred name should be communicated here see drugdescription docid 3rte j4sqyuy ywhpoil best practices section for more information drugcoded conditional ndc mandatory the ndc must be a valid 11 digit code and should meet the qualifications for a representative ndc productcode conditional product identifier the representative ndc is recommended unless the message contains quantity code list qualifier “cf” or the compoundinformation element is present see ndc codes docid 3rte j4sqyuy ywhpoil for more information strength conditional strengthform/code conditional must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes docid\ b72tynfwse2b mcsxlvhl for details strengthunitofmeasure/code conditional must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes docid\ b72tynfwse2b mcsxlvhl for details quantity mandatory quantityunitofmeasure mandatory must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes docid\ b72tynfwse2b mcsxlvhl for details padayssupplydoseperday conditional medicationprescribed/dayssupply or padayssupply and padosesperday must be a whole number just one of these fields need to be submitted note in order to allow pbm/payers to provide the most accurate response, provider vendors should include dayssupply for the requested medication within painitiationrequests pbm/payers use days supply in order to determine if prescribers are requesting a quantity outside of the plan limit failure to provide days supply could result in unnecessary question sets being returned to prescribers or additional work diagnosis conditional provider vendors should send the valid version of diagnosis codes in the painitiationrequest sending diagnosis codes may speed up the process note if sending icd 10 codes (qualifier abf), sending systems should not include decimal codes for message/submission clinicalinformationqualifier mandatory qualifier for how the diagnosis was obtained values 1 prescriber/prescriber supplied 2 pharmacy inferred 3 patient 4 other source qualifier mandatory defines the code list used for the diagnosis code value mandatory code for the diagnosis description mandatory description of the diagnosis code sig conditional sigtext mandatory sigtext will be used to convey patient instructions for use or administration and should be constructed and transmitted in a patient friendly manner sigs should not be truncated because important information can be lost provider note the provider loop can offer additional contacts beyond the prescriber if there were follow up questions to the painitiationrequest identification conditional npi mandatory npi of the initiating party name mandatory initiating party’s name see acr pa 204 in the application certification requirements docid\ s0azhqcpqwqhk9l9dqi1r section for more information communicationnumbers mandatory primarytelephone mandatory initiating party’s phone number see acr pa 204 in the application certification requirements docid\ s0azhqcpqwqhk9l9dqi1r section for more information fax conditional initiating party’s fax number address mandatory parent element for patient address information addressline1 mandatory patient’s primary address line city mandatory patient’s city stateprovince conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience postalcode conditional changed from mandatory in v2017071 to conditional recommended for optimal epa experience