Message Example
3 min
PA Submitted by a Person Other than the Prescriber
In this example, the initiator of the prior authorization process is a staff member in the provider vendor’s organization who can be reached at a different phone number than the prescriber. To provide this additional contact information, the ePA standard enables the initiating person to provide their separate contact information in the Provider element of the prior authorization message (see Provider Elements in the NCPDP SCRIPT Implementation Guide for more information). If the PBM/payer needs to call or fax the initiator during processing, it uses the contact information contained in this Provider element rather than the phone or fax in the Prescriber segment.
The requested medication is Lovenox (Lovenox 40 MG Per 0.4 ML Prefilled Syringe; RxNorm SBD 854236; NDC 58016487201).
This example does not include the Status messages or any other part of the normal message flow.
PAInitiationRequest (from Initiating Party)
PAInitiationRequest (from Initiating Party)<?xml version="1.0" encoding="utf-8"?>
<Message DatatypesVersion="20230115" TransportVersion="20230115" TransactionDomain="SCRIPT"
TransactionVersion="20230115" StructuresVersion="20230115" ECLVersion="20230115">
<Header>
<To Qualifier="ZZZ">EPAINI</To>
<From Qualifier="D">6842917100001</From>
<MessageID>4e55ea3f923b4e14a436a3f08554f488</MessageID>
<SentTime>2015-09-04T17🔞14.1Z</SentTime>
<SenderSoftware>
<SenderSoftwareDeveloper>MDLITE</SenderSoftwareDeveloper>
<SenderSoftwareProduct>443</SenderSoftwareProduct>
<SenderSoftwareVersionRelease>2.1</SenderSoftwareVersionRelease>
</SenderSoftware>
<TestMessage>false</TestMessage>
</Header>
<Body>
<PAInitiationRequest>
<PAReferenceID>c7eb89cc8a3c43c8818e456627a91c2d</PAReferenceID>
<BenefitsCoordination>
<PayerIdentification>
<PayerID>P00000000001192</PayerID>
<ProcessorIdentificationNumber>PCN9110</ProcessorIdentificationNumber>
<IINNumber>994336</IINNumber>
</PayerIdentification>
<PayerName>PBMA</PayerName>
<CardholderID>209837423</CardholderID>
<CardHolderName>
<LastName>JOHNSON</LastName>
<FirstName>RONALD</FirstName>
<MiddleName>C</MiddleName>
</CardHolderName>
<GroupID>0998723</GroupID>
<GroupName>9110/3TIER/25</GroupName>
<PBMMemberID>0398473070389475</PBMMemberID>
</BenefitsCoordination>
<Patient>
<HumanPatient>
<Identification>
<MedicareBeneficiaryID>333445556A</MedicareBeneficiaryID>
</Identification>
<Names>
<Name>
<LastName>SMITH</LastName>
<FirstName>MAUREEN</FirstName>
</Name>
</Names>
<GenderAndSex>
<AdministrativeGender>F</AdministrativeGender>
</GenderAndSex>
<DateOfBirth>
<Date>1934-11-27</Date>
</DateOfBirth>
<Address>
<AddressLine1>201 GOLDEN LANE</AddressLine1>
<AddressLine2>APT 204</AddressLine2>
<City>CINCINNATI</City>
<StateProvince>OH</StateProvince>
<PostalCode>45233</PostalCode>
<CountryCode>US</CountryCode>
</Address>
</HumanPatient>
</Patient>
<Pharmacy>
<Identification>
<NCPDPID>7701631</NCPDPID>
<NPI>7878787879</NPI>
</Identification>
<BusinessName>CINCINNATI PHARMACY</BusinessName>
<Address>
<AddressLine1>100 OMNIBUS LANE</AddressLine1>
<City>CINCINNATI</City>
<StateProvince>OH</StateProvince>
<PostalCode>45202</PostalCode>
<CountryCode>US</CountryCode>
</Address>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>8595559000</Number>
</PrimaryTelephone>
</CommunicationNumbers>
</Pharmacy>
<Prescriber>
<NonVeterinarian>
<Identification>
<NPI>1992091797</NPI>
</Identification>
<Names>
<Name>
<LastName>ePA-MessageManager30</LastName>
<FirstName>Provider</FirstName>
</Name>
</Names>
<Address>
<AddressLine1>123 Main st</AddressLine1>
<City>Minneapolis</City>
<StateProvince>MN</StateProvince>
<PostalCode>55123</PostalCode>
<CountryCode>US</CountryCode>
</Address>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>6518553000</Number>
</PrimaryTelephone>
<Fax>
<Number>6518553001</Number>
</Fax>
</CommunicationNumbers>
</NonVeterinarian>
</Prescriber>
<MedicationPrescribed>
<DrugDescription>LOVENOX 40 MG PER 0.4 ML PREFILLED SYRINGE</DrugDescription>
<Product>
<DrugCoded>
<NDC>58016487201</NDC>
<Strength>
<StrengthValue>100</StrengthValue>
<StrengthForm>
<Code>C42945</Code>
</StrengthForm>
<StrengthUnitOfMeasure>
<Code>C42576</Code>
</StrengthUnitOfMeasure>
</Strength>
</DrugCoded>
</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>
<Provider>
<Identification>
<NPI>7777777777</NPI>
</Identification>
<Names>
<Name>
<LastName>WEISS</LastName>
<FirstName>TERRY</FirstName>
<Suffix>RN</Suffix>
</Name>
</Names>
<CommunicationNumbers>
<PrimaryTelephone>
<Number>8595559880</Number>
</PrimaryTelephone>
<Fax>
<Number>8595559770</Number>
</Fax>
</CommunicationNumbers>
</Provider>
</PAInitiationRequest>
</Body>
</Message>