PAResponse (from PBM/Payer)
The PBM/payer reviews the prescriber’s PARequest and determines that it needs additional information. The PBM/payer returns a PAResponse containing another question set with one follow-up question.
<?xml version="1.0" encoding="utf-8"?>
<Message DatatypesVersion="20230115" TransportVersion="20230115" TransactionDomain="SCRIPT"
TransactionVersion="20230115" StructuresVersion="20230115" ECLVersion="20230115">
<Header>
<To Qualifier="D">7777777</To>
<From Qualifier="PY">P99999999999999</From>
<MessageID>8890</MessageID>
<RelatesToMessageID>1234569</RelatesToMessageID>
<SentTime>2014-12-02T17:05:12.1Z</SentTime>
<Security>
<Sender>
<TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
</Sender>
<Receiver>
<TertiaryIdentification>ACCT_ID_INSERTED_BY_SS</TertiaryIdentification>
</Receiver>
</Security>
<SenderSoftware>
<SenderSoftwareDeveloper>MD80SYSTEM</SenderSoftwareDeveloper>
<SenderSoftwareProduct>80</SenderSoftwareProduct>
<SenderSoftwareVersionRelease>15.2</SenderSoftwareVersionRelease>
</SenderSoftware>
</Header>
<Body>
<PAResponse>
<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>
<Response>
<ResponseStatus>
<Open>
<PACaseID>A101</PACaseID>
<MoreInformationRequired>
<Header>
<QuestionSetID>QS101-FOLLOWUP</QuestionSetID>
<QuestionSetTitle>Lovenox PA Form - Follow up question(s)</QuestionSetTitle>
<QuestionSetDescription>Thank you for your request. The additional information identified here is required to finish processing the case. Please provide at your earliest convenience; the case will remain open until the date specified in this message.</QuestionSetDescription>
<QuestionSetContactCommunicationNumber>
<PrimaryTelephone>
<Number>5555551212</Number>
</PrimaryTelephone>
</QuestionSetContactCommunicationNumber>
<AttachmentRequired>false</AttachmentRequired>
</Header>
<Question>
<QuestionID>FOLLOWUP_Q1</QuestionID>
<SequenceNumber>1</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>
</FreeText>
</QuestionType>
</Question>
<DeadlineForReply>
<DateTime>2014-10-02T23:59:59</DateTime>
</DeadlineForReply>
</MoreInformationRequired>
<PANote>We currently cannot process CDA documents. Please answer this question regarding the patient's previous use of Warfarin either by entering free text or by attaching a PDF document. Thank you!</PANote>
</Open>
</ResponseStatus>
</Response>
</PAResponse>
</Body>
</Message>PAResponse (from PBM/payer) Example Element Details
Note: The table below does not explain every element displayed in the XML example.
Element | Value | Note |
|---|---|---|
To | 77777777:D | ID of the prescriber; D is the qualifier for a Prescriber ID. |
From | P99999999999999:PY | ID of the sending PBM/payer; PY means it is the payer. |
MessageID | 8890 | PBM/payer system trace number for the transmission. Echoed back in the response message in RelatesToMessageID. |
RelatesToMessageID | 1234569 | Used to link the most recent message received from a trading partner in the conversation to this subsequent message. |
SentTime | 2014-12-02T17:05:12.1Z | Date and time message was sent: 12/02/2014 17:05:12.1 PM |
PAResponse | PAResponse | Message type. |
SenderSoftwareDeveloper, SenderSoftwareProduct, SenderSoftwareVersionRelease | MD80SYSTEM:80:15.2 | Sender Software Developer: MD80SYSTEM Sender Software Product: 80 Sender Software Version Release: 15.2 |
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 | 6152219800 | 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. |
Response | | |
PACaseID | A101 | PBM/payer-assigned identifier for this request. |
ResponseStatus | Open | |
DeadlineForReply | 2014-10-02T23:59:59 | Deadline for responding to this case in datetime format. |
QuestionSet | | |
QuestionSet | | A question set is included in the PBM/payer’s response. |
Header | | |
QuestionSetID | QS101-FOLLOWUP | PBM/payer-assigned ID for this question set. |
QuestionSetTitle | Lovenox PA Form - Follow up question(s) | Title of the question set, "Lovenox PA Form - Follow up question(s)" can be presented to the end-user. |
QuestionSetDescription | Thank you for your request. The additional information identified here is required to finish processing the case. Please provide at your earliest convenience; the case will remain open until the date specified in this message. | 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 | FOLLOWUP_Q1 | 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 | 1 | Order of this question relative to other questions in this question set. |
IsFreeText | Y | Indicates this is a free text question. (Yes) |