Message Examples

🟪 audience pbms/payers + provider/ehr vendors this content applies to both trading partner types and includes requirements or workflows shared across both sides of the transaction full eligibility response message example isa 00 01 pwphy12345 zz pbm123456789123 zz s00000000000001 171217 0345 ^ 00501 000000001 1 p \[ gs hb pbm123456789123 s00000000000001 20171217 16150000 1 x 005010x279a1 st 271 0001 005010x279a1 bht 0022 11 3920394930203 20171217 16150000 hl 1 20 1 nm1 2b 2 pbm company pi pbm123456789123 hl 2 1 21 1 nm1 1p 1 jonson tim t m d xx 3334444555 ref eo p01234567891234 hl 3 2 22 0 nm1 il 1 cross david m mi dd145645645601 ref 49 01 n3 6785 laughalot lane n4 trenton nj 08608 dmg d8 19720910 m ins y 18 dtp 291 d8 20171217 eb 1 30 mc medicaidplan ref 6p mxd 55 maxd271 ref fo fsl 55 cov pe55 ref cli cov 55 cov pa55 ref ig cop 55 pn pa55 ref als alt 55 cov st55 ref n6 003044 medi mx 3044 dtp 291 rd8 20250901 20991231 msg agalt 55 msg pscop 55 msg mecov me55 msg qlcov ql55 msg smcov st55 msg spcov sp55 msg alcov al55 msg glcov gl55 msg gmcov gm55 msg pcpc pa55 ls 2120 nm1 sep 2 pbm company pi pbm123456789123 le 2110 eb 1 88 eb 1 90 se 29 0001 ge 1 1 iea 1 000000001 formulary file examples version 3 0 examples formulary status list fhd|fsl 55|formulary 55|1|1|2|2|u|0|f|20260101 fdt|a|00378531001|36|||||4| fdt|a|00228348211|36|||||4| fdt|a|00378527201|36|||||3| fdt|a|43598000351|36|||||2| fdt|a|16714061101|36|||||5| fdt|a|71610042560|36|||||4| fdt|a|13668047330|36|||||2| ftr|8 payer preferred alternatives list ahd|alt 55|f|20260101 adt|a|00456221230|36|||||00093738505|36|||||5 adt|a|00456221230|36|||||00093754206|36|||||4 adt|a|00456221230|36|||||44183089031|36|||||3 adt|a|70074062749|36|||||70074062481|36|||||3 adt|a|70074062749|36|||||70074062803|36|||||2 adt|a|52083063316|36|||||82028000118|36|||||3 adt|a|52083063316|36|||||82028000087|36|||||2 atr|7 gender limits list ghd|pbm gl55gl|gl|f|20260101 gdt|a|cov gl55|00069421066|36|||||1 gdt|a|cov gl55|00069422030|36|||||1 gdt|a|cov gl55|00069420030|36|||||1 gdt|a|cov gl55|00378462016|36|||||2 gdt|a|cov gl55|00378462116|36|||||2 gtr|5 quantity limits list ghd|pbm ql55ql|ql|f|20260101 qdt|a|cov ql55|00004008694|36|||||112|ds|lt||| qdt|a|cov ql55|00004023709|36|||||90|qy|dy|||26 qdt|a|cov ql55|00004024126|36|||||20|qy|dy|||26 qdt|a|cov ql55|00004027301|36|||||20|qy|dy|||26 qdt|a|cov ql55|00004035039|36|||||112|ds|lt||| qdt|a|cov ql55|00004035239|36|||||112|ds|lt||| qdt|a|cov ql55|00004080007|36|||||1|fl|dy|||180 gtr|7 prior authorization list ghd|pbm pa55pa|pa|f|20260101 ddt|a|cov pa55|00025152551|36|||| ddt|a|cov pa55|00591040701|36|||| ddt|a|cov pa55|54092051702|36|||| ddt|a|cov pa55|59011044010|36|||| gtr|4 version 60 examples formulary status file fhd|fsl 55|x|n|o|p|p|o|20260211|20991231 fdt|00054006447|36|||||o|||| fdt|55513053001|36|||||p|8||| fdt|00409272002|36|||||o|||| ftr|3 prior authorization file prh|cov pa55|20260211|20991231||| prd|00168041630|36||||||| prd|00025292431|36||||||| prd|00054006447|36||||||| prd|00186037220|36||||||| prd|00310757090|36||||||| prd|59148000813|36||||||| prd|55513053001|36||||||| prt|7 quantity limit file qlh|cov ql55|20260211|20991231| qld|55513053001|36|||||15|qy|c120216|ac|pd|||| qld|00069019501|36|||||14 0|ds|||lt|||| qld|00406113052|36|||||6 0|qy|c64933|ac|dy|||26| qld|00173056200|36|||||9 0|qy|c48542|ac|dy|||26| qld|35356046030|36|||||6 0|qy|c48506|ac|dy|||26| qld|60846013030|36|||||225 0|dl|||dy|||26| qlt|6 gender limits file glh|cov gl55|20260211|20991231| gld|00024583701|36|||||u|m| gld|00009041702|36|||||u|m| gld|00002446230|36|||||u|m| gld|00002446330|36|||||u|m| gld|52244004002|36|||||u|m| glt|5