PAResponse Elements

1 min

Element	Code	Comments
PAResponse
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).
BenefitsCoordination
PBMMemberID	conditional	PBM/payer-assigned member ID for the patient.
Patient Note: Refer to the schema for a complete list of fields.
Identification	conditional
SocialSecurity	conditional	Patient’s Social Security Number.
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.
Pharmacy
Identification	mandatory
NCPDPID	mandatory	NCPDP Provider ID Number of Pharmacy.
NPI	mandatory	National Provider ID of Pharmacy.
BuisnessName	mandatory	Name of Pharmacy.
CommunicationNumbers	mandatory	Phone Number of Pharmacy.
Prescriber Note: The prescriber relates to the person requesting the prior authorization.
Identification	mandatory
NPI	mandatory	NPI of the Prescriber.
CommunicationNumbers	mandatory	Prescriber’s phone number.
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.