PARequest (from Prescriber – Initial Submission)
2 min
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