PAInitiationRequest Elements

1 min

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 RequestsSending Prior Authorization Initiation Requests 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 DrugDescriptionDrugDescription 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 CodesNDC Codes for more information.
Strength	conditional
StrengthForm/Code	conditional	Must be a valid FMT code. See Codified Field Usage for Federal Medication Terminologies (FMT) CodesCodified Field Usage for Federal Medication Terminologies (FMT) Codes for details.
StrengthUnitOfMeasure/Code	conditional	Must be a valid FMT code. See Codified Field Usage for Federal Medication Terminologies (FMT) CodesCodified Field Usage for Federal Medication Terminologies (FMT) Codes for details.
Quantity	mandatory
QuantityUnitOfMeasure	mandatory	Must be a valid FMT code. See Codified Field Usage for Federal Medication Terminologies (FMT) CodesCodified Field Usage for Federal Medication Terminologies (FMT) Codes 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 RequirementsApplication Certification Requirements section for more information.
CommunicationNumbers	mandatory
PrimaryTelephone	mandatory	Initiating party’s phone number. See ACR PA.204 in the Application Certification RequirementsApplication Certification Requirements 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.