PARequest (from Prescriber – Initial Submission)
The prescriber provides the information for the follow-up question in the format indicated in the question set (by attaching a PDF document to the PARequest message).
<?xml version="1.0" encoding="utf-8"?>
<Message DatatypesVersion="20230115" TransportVersion="20230115" TransactionDomain="SCRIPT"
TransactionVersion="20230115" StructuresVersion="20230115" ECLVersion="20230115">
<Header>
<To Qualifier="PY">P99999999999999</To>
<From Qualifier="D">77777777</From>
<MessageID>1234569</MessageID>
<RelatesToMessageID>1234567</RelatesToMessageID>
<SentTime>2014-07-02T14:12:14.1Z</SentTime>
<Security>
<Sender>
<TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
</Sender>
<Receiver>
<TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
</Receiver>
</Security>
<SenderSoftware>
<SenderSoftwareDeveloper>MDLITE</SenderSoftwareDeveloper>
<SenderSoftwareProduct>443</SenderSoftwareProduct>
<SenderSoftwareVersionRelease>2.1</SenderSoftwareVersionRelease>
</SenderSoftware>
</Header>
<Body>
<PARequest>
<PAReferenceID>77XX2</PAReferenceID>
<BenefitsCoordination>
<PBMMemberID>333445555</PBMMemberID>
</BenefitsCoordination>
<Patient>
<HumanPatient>
<Names>
<Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<LastName>SMITH</LastName>
<FirstName>MARY</FirstName>
</Name>
</Names>
<GenderAndSex>
<AdministrativeGender>F</AdministrativeGender>
</GenderAndSex>
<DateOfBirth>
<Date>1954-12-25</Date>
</DateOfBirth>
<Address>
<AddressLine1>45 EAST ROAD SW</AddressLine1>
<City>CLANCY</City>
<StateProvince>WI</StateProvince>
<PostalCode>54999</PostalCode>
<CountryCode>US</CountryCode>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NCPDPID>7701630</NCPDPID>
<NPI>7878787878</NPI>
</Identification>
<BusinessName>MAIN STREET PHARMACY</BusinessName>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>6155555656</Number>
</PrimaryTelephone>
</CommunicationNumbers>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>666666666</NPI>
</Identification>
<Names>
<Name xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<LastName>JONES</LastName>
<FirstName>MARK</FirstName>
</Name>
</Names>
<Address>
<AddressLine1>211 CENTRAL ROAD</AddressLine1>
<City>JONESVILLE</City>
<StateProvince>TN</StateProvince>
<PostalCode>37777</PostalCode>
<CountryCode>US</CountryCode>
</Address>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>6152219800</Number>
</PrimaryTelephone>
</CommunicationNumbers>
</NonVeterinarian>
</Prescriber>
<MedicationPrescribed>
<DrugDescription xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE</DrugDescription>
<Product>
<NonDrugCoded>
<Strength>
<StrengthValue>100</StrengthValue>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<StrengthUnitOfMeasure>
<Code>C42576</Code>
</StrengthUnitOfMeasure>
</Strength>
</NonDrugCoded>
</Product>
<Quantity>
<Value>30</Value>
<CodeListQualifier>38</CodeListQualifier>
<QuantityUnitOfMeasure>
<Code>C48540</Code>
</QuantityUnitOfMeasure>
</Quantity>
<DaysSupply>30</DaysSupply>
<Diagnosis>
<ClinicalInformationQualifier>1</ClinicalInformationQualifier>
<Qualifier>ABF</Qualifier>
<Value>E11.9</Value>
<Description>DIABETES MELLITUS</Description>
</Diagnosis>
<Sig>
<SigText>INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY</SigText>
</Sig>
</MedicationPrescribed>
<Attachment>
<AttachmentSource>Patient Medical Record</AttachmentSource>
<AttachmentData />
<CDA>
<TemplateID>2.16.840.1.113883.10.20.22.1.2</TemplateID>
</CDA>
<MIMEType>application/hl7-sda+xml</MIMEType>
</Attachment>
<Request>
<SolicitedModel>
<PACaseID>A101</PACaseID>
<DeadlineForReply>
<DateTime>2014-10-01T23:59:59</DateTime>
</DeadlineForReply>
<QuestionSet>
<Header>
<QuestionSetID>QS101</QuestionSetID>
<QuestionSetTitle>Lovenox PA Form</QuestionSetTitle>
<QuestionSetDescription>Please provide all information requested. Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information.</QuestionSetDescription>
<QuestionSetContactCommunicationNumber>
<PrimaryTelephone>
<Number>5555551212</Number>
</PrimaryTelephone>
</QuestionSetContactCommunicationNumber>
<AttachmentRequired>false</AttachmentRequired>
</Header>
<Question>
<QuestionID>Q1</QuestionID>
<SequenceNumber>1</SequenceNumber>
<QuestionText>Is this patient home self-administering?</QuestionText>
<DefaultNextQuestionID>Q2</DefaultNextQuestionID>
<QuestionType>
<Select>
<SelectMultiple>false</SelectMultiple>
<Choice>
<ChoiceID>Q1C1</ChoiceID>
<SequenceNumber>1</SequenceNumber>
<ChoiceText>Yes</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
</Choice>
<Choice>
<ChoiceID>Q1C2</ChoiceID>
<SequenceNumber>2</SequenceNumber>
<ChoiceText>No</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
</Choice>
<Answer>
<SubmitterProvidedAnswer>
<ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q1C1</ChoiceID>
</SubmitterProvidedAnswer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionID>Q2</QuestionID>
<SequenceNumber>2</SequenceNumber>
<QuestionText>Is the medication to be used to treat prophylaxis?</QuestionText>
<QuestionType>
<Select>
<SelectMultiple>false</SelectMultiple>
<Choice>
<ChoiceID>Q2C1</ChoiceID>
<SequenceNumber>1</SequenceNumber>
<ChoiceText>Yes</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
<NextQuestionID>Q3</NextQuestionID>
</Choice>
<Choice>
<ChoiceID>Q2C2</ChoiceID>
<SequenceNumber>2</SequenceNumber>
<ChoiceText>No</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
<NextQuestionID>Q4</NextQuestionID>
</Choice>
<Answer>
<SubmitterProvidedAnswer>
<ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q2C2</ChoiceID>
</SubmitterProvidedAnswer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionID>Q3</QuestionID>
<SequenceNumber>3</SequenceNumber>
<QuestionText>When was or will the surgery be done?</QuestionText>
<DefaultNextQuestionID>Q6</DefaultNextQuestionID>
<QuestionType>
<Date>
<IsDateTimeRequired>false</IsDateTimeRequired>
</Date>
</QuestionType>
</Question>
<Question>
<QuestionID>Q4</QuestionID>
<SequenceNumber>4</SequenceNumber>
<QuestionText>Is the medication to be used for treatment of DVT?</QuestionText>
<QuestionType>
<Select>
<SelectMultiple>false</SelectMultiple>
<Choice>
<ChoiceID>Q4C1</ChoiceID>
<SequenceNumber>1</SequenceNumber>
<ChoiceText>Yes</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
<NextQuestionID>Q5</NextQuestionID>
</Choice>
<Choice>
<ChoiceID>Q4C2</ChoiceID>
<SequenceNumber>2</SequenceNumber>
<ChoiceText>No</ChoiceText>
<AdditionalFreeTextIndicator>NA</AdditionalFreeTextIndicator>
<NextQuestionID>Q6</NextQuestionID>
</Choice>
<Answer>
<SubmitterProvidedAnswer>
<ChoiceID xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">Q4C1</ChoiceID>
</SubmitterProvidedAnswer>
</Answer>
</Select>
</QuestionType>
</Question>
<Question>
<QuestionID>Q5</QuestionID>
<SequenceNumber>5</SequenceNumber>
<QuestionText>What is the patient's weight (in pounds)?</QuestionText>
<DefaultNextQuestionID>Q6</DefaultNextQuestionID>
<QuestionType>
<Numeric>
<IsNumeric>true</IsNumeric>
<Answer>
<SubmitterProvidedNumericAnswer>164</SubmitterProvidedNumericAnswer>
</Answer>
</Numeric>
</QuestionType>
</Question>
<Question>
<QuestionID>Q6</QuestionID>
<SequenceNumber>6</SequenceNumber>
<QuestionText>Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin. You may attach supporting information in a PDF document.</QuestionText>
<DefaultNextQuestionID>END</DefaultNextQuestionID>
<QuestionType>
<FreeText>
<IsFreeText>true</IsFreeText>
<Answer>
<SubmitterProvidedAnswer>Patient tried Warfarin without success. See attached CCD with treatment history.</SubmitterProvidedAnswer>
</Answer>
</FreeText>
</QuestionType>
</Question>
</QuestionSet>
</SolicitedModel>
</Request>
</PARequest>
</Body>
</Message>PARequest (from Prescriber) Example Element Details
Note: The table below does not explain every element displayed in the XML example.
Element | Value | |
|---|---|---|
To | P99999999999999:PY | ID of the receiving PBM/payer; PY means it is the payer. |
From | 77777777:D | SPI assigned to the prescriber; D is the qualifier for a Prescriber ID. |
MessageID | 1234569 | Initiating system trace number for the transmission. Echoed back in the response message in RelatesToMessageID. |
RelatesToMessageID | 1234567 | Used to link the most recent message received from a trading partner in the conversation to this subsequent message. |
SentTime | 2014-07-02T14🕛14.1Z | Date and time message was sent: 07/02/2014 14🕛14.1 PM |
PARequest | PARequest | Message type. |
SenderSoftwareDeveloper, SenderSoftwareProduct, SenderSoftwareVersionRelease | MDLITE:443:2.1 | Sender Software Developer: MDLITE Sender Software Product: 443 Sender Software Version Release: 2.1 |
PrescriberOrderNumber | | Not sent. Not applicable. |
RxReferenceNumber | | Not sent. Not applicable. |
PAReferenceID | 77XX2 | 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). |
PBMMemberID | 333445555 | PBM/payer-assigned member ID for the patient. |
SocialSecurity | 333445555 | Patient’s Social Security Number. |
LastName, FirstName | SMITH:MARY | Patient’s name. |
Gender | F | Patient's gender. |
DateOfBirth | 1954-12-25 | Patient’s date of birth. |
Address | 45 EAST ROAD SW, CLANCY, WI, 54999 | Patient’s address. |
NCPDPID | 7701630 | NCPDP Provider ID Number of Pharmacy. |
NPI | 7878787878 | National Provider ID of Pharmacy. |
StoreName | MAIN STR... | Name of Pharmacy. |
CommunicationNumber | 6155555656 | Phone Number of Pharmacy. |
NPI | 666666666 | NPI of the Prescriber. |
LastName, FirstName | JONES:MARK | Prescriber’s name. |
Address | 211 CENTRAL ROAD, JONESVILLE, TN, 37777 | Prescriber’s address. |
CommunicationNumber | 6155559800 | Prescriber’s phone number. |
DrugDescription | LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE | Drug prescribed is Lovenox 40 MG per 0.4 ML Prefilled Syringe. |
Strength | 100 | 100 is the strength. |
StrengthForm | C42945 | C42945 is the code for "injectable solution". |
StrengthUnitOfMeasure | C42576 | C42576 is the code for "milligrams per milliliter". |
Quantity | 30:38 | Quantity is 30. 38 is the code value for Original Qty. |
QuantityUnitOfMeasure | C48540 | C48540 is the code for "Syringe". |
DaysSupply | 30 | 30 is the number of days supply. |
Diagnosis Code | E11.9 | E11.9 is the diagnosis code for Diabetes mellitus. |
SigText | INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY | INJECT 40 MG SUBCUTANEOUSLY ONCE DAILY... is the Sig. |
Attachment | ||
AttachmentSource | Patient medical record | Indicates that the information was retrieved from the patient’s medical record. |
AttachmentData | Base64-encoded CCD document | Attached CCD document (BASE64 encoded). |
CDA:TemplateID | 2.16.840.1.113883.10.20.22.1.2 | CDA TemplateID for the Continuity of Care Document (CCD). |
MIMEType | application/hl7-sda+xml | MIME type for CDA documents. |
Request | ||
SolicitedModel | SolicitedModel | |
PACaseID | A101 | PBM/payer-assigned identifier for this request. |
DeadlineForReply | 2014-10-01T23:59:59 | Deadline for response (echoed from PAInitiationResponse). |
QuestionSet | ||
QuestionSet | | A question set is included in the PBM/payer’s response. |
Header | | |
QuestionSetID | QS101 | PBM/payer-assigned ID for this question set. |
QuestionSetTitle | Lovenox PA Form | Title of the question set, "Lovenox PA Form" can be presented to the end-user. |
QuestionSetDescription | Please provide all information requested. Failure to complete this form in its entirety may result in delayed processing or an adverse determination for insufficient information. | Instructions for the end-user. |
QuestionSetContactPhoneNumber | 5555551212 | Contact phone number at the PBM/payer for questions related to this PA process. |
AttachementRequired | N | |
Question 1 | ||
Question | | |
QuestionID | Q1 | PBM/payer-assigned ID for this question. |
QuestionText | Is this patient home self-administering? | Question text to be displayed to the end-user. |
SequenceNumber | 1 | Order of this question relative to other questions in this question set. |
DefaultNextQuestionID | Q2 | Next question to display regardless of the answer to this question. |
Select | | Type of this question is Select. |
SelectMultiple | N | Only one answer may be returned for this question. (No) |
Choice - First choice | | |
ChoiceID | Q1C1 | PBM/payer-assigned ID for this choice. |
ChoiceText | Yes | Text to be presented to the end-user. |
SequenceNumber | 1 | Order of this choice relative to other choices for this question. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Choice - Second choice | | |
ChoiceID | Q1C2 | PBM/payer-assigned ID for this choice. |
ChoiceText | No | Text to be presented to the end-user. |
SequenceNumber | 2 | Order of this choice relative to other choices for this question. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Answer | | |
PrescriberProvidedAnswer | | |
ChoiceID | Q1C1 | ChoiceID associated with the selected choice. |
Question 2 | ||
Question | | |
QuestionID | Q2 | PBM/payer-assigned ID for this question. |
QuestionText | Is the medication to be used to treat prophylaxis? | Question text to be displayed to the end-user. |
SequenceNumber | 2 | Order of this question relative to other questions in this question set. |
Select | | Type of this question is Select. |
SelectMultiple | N | Only one answer may be returned for this question. (No) |
Choice | | First choice |
ChoiceID | Q2C1 | PBM/payer-assigned ID for this choice. |
ChoiceText | Yes | Text to be presented to the end-user. |
SequenceNumber | 1 | Order of this choice relative to other choices for this question. |
NextQuestionID | Q3 | Next question to be answered if this choice is selected. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Choice | | Second choice |
ChoiceID | Q2C2 | PBM/payer-assigned ID for this choice. |
ChoiceText | No | Text to be presented to the end-user. |
SequenceNumber | 2 | Order of this choice relative to other choices for this question. |
NextQuestionID | Q4 | Next question to be answered if this choice is selected. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Answer | | |
PrescriberProvidedAnswer | | |
ChoiceID | Q2C2 | ChoiceID associated with the selected choice. |
Question 3 - Conditional question to be asked if Question 2 answer is Yes | ||
Question | | |
QuestionID | Q3 | PBM/payer-assigned ID for this question. |
QuestionText | When was or will the surgery be done? | Question text to be displayed to the end-user. |
SequenceNumber | 3 | Order of this question relative to other questions in this question set. |
DefaultNextQuestionID | Q6 | Next question to display regardless of the answer to this question. |
Date | | Type of this question is Date. |
IsDateTimeRequired | N | Time information is not required in the response to this question. (No) |
Note: This question was not answered based on the NextQuestionID of the previously selected answer. | | |
Question 4 | ||
Question | | |
QuestionID | Q4 | PBM/payer-assigned ID for this question. |
QuestionText | Is the medication to be used for treatment of DVT? | Question text to be displayed to the end-user. |
SequenceNumber | 4 | Order of this question relative to other questions in this question set. |
Select | | Type of this question is Select. |
SelectMultiple | N | Only one answer may be returned for this question. (No) |
Choice - First choice | ||
ChoiceID | Q4C1 | PBM/payer-assigned ID for this choice. |
ChoiceText | Yes | Text to be presented to the end-user. |
SequenceNumber | 1 | Order of this choice relative to other choices for this question. |
NextQuestionID | Q5 | Next question to be answered if this choice is selected. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Choice - Second choice | ||
ChoiceID | Q4C2 | PBM/payer-assigned ID for this choice. |
ChoiceText | No | Text to be presented to the end-user. |
SequenceNumber | 2 | Order of this choice relative to other choices for this question. |
NextQuestionID | Q6 | Next question to be answered if this choice is selected. |
AdditionalFreeTextIndicator | NA | No additional free text is allowed when selecting this choice. |
Answer | | |
PrescriberProvidedAnswer | | |
ChoiceID | Q4C1 | ChoiceID associated with the selected choice. |
Question 5 - Conditional question to be asked if previous question’s answer is Yes | ||
Question | | |
QuestionID | Q5 | PBM/payer-assigned ID for this question. |
QuestionText | What is the patient’s current weight (in pounds)? | Question text to be displayed to the end-user. |
DefaultNextQuestionID | Q6 | Next question to display regardless of the answer to this question. |
SequenceNumber | 5 | Order of this question relative to other questions in this question set. |
IsNumeric | | Type of this question is Numeric. |
Answer | | |
PrescriberProvidedAnswer | 164 | |
Question 6 | ||
Question | | |
QuestionID | Q6 | PBM/payer-assigned ID for this question. |
QuestionText | Describe result of Warfarin use (include INR and date drawn) or reason why patient can't use Warfarin. You may attach supporting information in a PDF document. | Question text to be displayed to the end-user. |
DefaultNextQuestionID | END | Last question in the question set. |
SequenceNumber | 6 | Order of this question relative to other questions in this question set. |
IsFreeText | Y | Indicates this is a free text question. (Yes) |
Answer | ||
PrescriberProvidedAnswer | Patient tried Warfarin without success. See attached CCD with treatment history. | |