Element Details

requirement designation element attributes code description mandatory the element must be used per the specification (e g , xml schema validation) conditional the element is to be used per the conditions specified business rule if sent, the element must be used per the surescripts business rule note not all business rules reside in this table recommended surescripts recommends sending the element as a best practice optional some fields do not have specific conditions data should be sent if available not used not used by surescripts this guide includes data elements only where surescripts has specific requirements or further explains the field usage refer to the schema for a complete list of fields element tables message header elements element code comments to mandatory the identification of the intended receiver of the message this field contains the identification number of the recipient for all painitiationrequests, this field contains epaini for all subsequent request messages, it will contain the participant id of the pbm/payer/third party processor for response messages, this field contains the spi of the provider vendor @qualifier conditional business rule if the to field is sent, then the qualifier must also be sent values d = prescriber id (used for spi) py = payer (pbm/payer or third party processor participant id) zzz = mutually defined (used when sending to epaini) from mandatory the identification of the sender of the message this field contains the identification number of the sender this field contains the spi (surescripts provider id) of the provider vendor, the participant id of the pbm/payer or third party processor, or epaini @qualifier conditional business rule if the from field is sent, then the qualifier must also be sent values d = prescriber id (used for spi) py = payer (pbm/payer or third party processor participant id) zzz = mutually defined (only used when surescripts is responding from epaini) messageid mandatory the sender should ensure the combination of the from and messageid elements is unique for at least 18 months surescripts recommends an unformatted globally unique identifier (guid) relatestomessageid conditional relates to message id is required by surescripts this field is the messageid of the most recent and relevant message in the workflow, including outside of only epa conversational messaging this is required for painitiationrequest, painitiationresponse, parequest, paresponse, paappealrequest, paappealresponse, pacancelrequest, pacancelresponse, error, verify, and status senttime mandatory date of the transmission please see utc time format https //docs surescripts com/epa accelerator/guide/integration and production#utc time format section sendersoftware mandatory identifies the entity responsible that generated the message contains the software vendor name, product, and version/release these fields were previously blocked by surescripts when passing the message on to the receiver they will now be passed on to the receiver sendersoftwaredeveloper mandatory identifies the entity responsible for the software that generated the message the developer may be a software vendor or, if the software was developed "in house", the developer is the entity actually sending the message (e g , a chain) the value transmitted is determined by the sender software developer sendersoftwareproduct mandatory the text field that identifies the software developer’s product, as determined by the software developer softwareversionrelease mandatory the text field that identifies the version and release of the software product, as determined by the software developer testmessage conditional when sent, allowable values must match platform that message is being sent to values 1 = test (required in staging environment) all other values = live (production) surescripts does not recommend sending this field within the production environment message indicator flag conditional not applicable to prior authorization transactions isa13 conditional this is the interchange control number isa13 value from the eligibility response x12 271 transaction painitiationrequest elements 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 see benefits coordination table in sending prior authorization initiation requests docid\ f scglko2h5cdro le8w0 for details on how the 271 response should be mapped to benefitscoordination 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 name mandatory surescripts may update prescriber/name/firstname and prescriber/name/lastname with data from the surescripts directory in painitiationrequest messages prior to sending them to pbm/payers specialty mandatory surescripts may update prescriber/specialty with data from the surescripts directory in painitiationrequest messages prior to sending them to pbm/payers address mandatory parent element for prescriber address information addressline1 mandatory prescriber’s primary address line city mandatory prescriber’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 drugdescription 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 codes https //docs surescripts com/epa accelerator/guide/best practices#ndc codes for more information strength conditional strengthform/code conditional must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes https //docs surescripts com/epa accelerator/guide/element details#codified field usage for federal medication termin for details strengthunitofmeasure/code conditional must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes https //docs surescripts com/epa accelerator/guide/element details#codified field usage for federal medication termin for details quantity mandatory quantityunitofmeasure mandatory must be a valid fmt code see codified field usage for federal medication terminologies (fmt) codes https //docs surescripts com/epa accelerator/guide/element details#codified field usage for federal medication termin 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 surescripts may parse the sig text field and use results to populate the dayssupply field when it is not sent in a painitiationrequest message prior to sending to the pbm/payer 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 requirements docid ws6g9uek88h4vx9 6zxi section for more information communicationnumbers mandatory primarytelephone mandatory initiating party’s phone number see acr pa 204 in the application certification requirements docid ws6g9uek88h4vx9 6zxi section for more information fax conditional initiating party’s fax number address mandatory parent element for provider address information addressline1 mandatory provider’s primary address line city mandatory provider’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 codified field usage for federal medication terminologies (fmt) codes for a list of fmt codes, go to http //evs nci nih gov/ftp1/ncpdp/about html http //evs nci nih gov/ftp1/ncpdp/about html use the valid value from the appropriate row of the downloaded data this list should be updated on a monthly basis the table below includes some example fields codified field/field code comment strengthform/code use the ncpdp strengthform terminology rows from the downloaded data this list should be updated on a monthly basis strengthunitofmeasure/code use the ncpdp strengthunitofmeasure terminology rows from the downloaded data quantityunitofmeasure/code use the ncpdp quantityunitofmeasure terminology rows from the downloaded data doseunitofmeasure/code use the ncpdp doseunitofmeasure terminology rows from the downloaded data deaschedule use the ncpdp deaschedule terminology rows from the downloaded data