This document maps API request fields to the ASC X12N 005010X211 transaction.

It is not applicable to ASC X12N 005010X210 claim attachment transactions unless explicitly stated.

Overview

This document describes how the Prior Authorization Attachment Submission API JSON request is translated into an ASC X12N 005010X211 (275) transaction. Please see Understanding JSON-to-EDI API Mapping.

The X211 implementation guide specifically supports Health Care Services Review workflows rather than claim adjudication workflows.

The mapping includes:

• JSON field
• EDI Loop
• EDI Segment
• Element Number
• X12 Description
• Usage
• Sample Value
• Business Context

The transaction hierarchy below follows the ASC X12N 005010X211 implementation guide.

1000A Information Source
   NM1
   PER

1000B Information Receiver
   NM1

1000C Patient
   NM1
   REF

2000A Attachment Detail
   LX
   TRN
   STC
   REF

2100A Additional Information
   DTP
   CAT

2110A Attachment Content
   EFI
   BIN

ISA
└── GS
    └── ST
        ├── BGN
        ├── 1000A Information Source
        ├── 1000B Information Receiver
        ├── 1000C Patient
        ├── 2000A Attachment Detail
        │     └── 2100A Additional Information
        │            └── 2110A Attachment Content
        └── SE

Envelope mapping

ISA interchange control header

GS functional group

ST transaction set

BGN beginning segment

📘

NOTE

Not every API field becomes an EDI segment. The 275X211 payload contains only the data required to support a health care services review request. API transport metadata (headers, correlation identifiers, timestamps, environment indicators, pagination attributes, etc.) are used by the API platform and are not included in the generated X12 transaction.

Loop 1000A Information Source Name

Submitting Provider/Dental Office

JSON Structure

{
  "informationSource": {
    "organizationName": "ABC Dental",
    "npi": "1234567890",
    "contactName": "John Smith",
    "phone": "8005551212"
  }
}

EDI mapping

NM1*1P*2*ABC DENTAL*****XX*1234567890~
PER*IC*JOHN SMITH*TE*8005551212~

Loop 1000B Information Receiver Name

Receiving Health Plan

JSON structure

{
  "informationReceiver": {
    "organizationName": "UnitedHealthcare",
    "payerId": "87726"
  }
}

EDI mapping

NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~

Loop 1000C Patient Name

JSON structure

{
  "patient": {
    "memberId": "987654321",
    "lastName": "DOE",
    "firstName": "JANE",
    "accountNumber": "12345"
  }
}

Mapping

NM1*QC*1*DOE*JANE****MI*987654321~
REF*EJ*12345~

Transaction type applicability

Loop 2000A Attachment Information Detail

Repeatable Loop

Each document submission generates a separate Loop 2000A instance.

LX Assigned Number

LX*1~

TRN Trace Number

TRN*2*PA123456~

STC Status Information

LOINC-driven identification for requested documentation.

STC*R4:27685-7::LOI~

Common Prior Authorization LOINC values:

REF Diagnostics

REF*ICD*K08.89~

REF Procedure

REF*CPT*D4341~

REF Service Trace Number

REF*FJ*ABC123~

Loop 2100A Additional Information

DTP

DTP*368*D8*20260825~

CAT Attachment Information

CAT*AE*IA~

Valid values

Loop 2110A Attachment Content

EFI External File Information

EFI*05~

BIN Binary Payload

BIN*10240*JVBERi0xLjQK...~

The BIN segment contains the actual attachment payload (PDF, TIFF, JPEG, CDA XML, etc.).

Prior Authorization Attachment (275 — X211)Example

ST*275*0003*005010X211~
BGN*11*99999*20240618~

NM1*X3*2*OPTUM UMO*****24*987654321~
NM1*IL*1*DOE*MARK****MI*444555666~

REF*EJ*PATIENTACC123~

LX*1~
TRN*2*UMOCTRL001~
STC*R4:11504-8::LOI~
REF*FJ*LINE1~
REF*CPT*27447~
DTP*368*D8*20240618~
CAT*AE*HL~
EFI*05~
BIN*150*VGhpcyBpcyBhIHNhbXBsZSBwYXlsb2Fk~

SE*14*0003~
``

API JSON

{
  "attachmentControlNumber": "PA123456",
  "memberId": "987654321",
  "diagnosisCode": "K08.89",
  "procedureCode": "D4341",
  "loincCode": "27685-7",
  "submissionDate": "20260825",
  "attachmentType": "IA",
  "file": {
    "byteCount": 5000,
    "content": "<base64-encoded-document>"
  }
}

Generated 275x211

ST*275*0003*005010X211~
BGN*11*99999*20240618~

NM1*X3*2*OPTUM UMO*****24*987654321~
NM1*IL*1*DOE*MARK****MI*444555666~

REF*EJ*PATIENTACC123~

LX*1~
TRN*2*UMOCTRL001~
STC*R4:11504-8::LOI~
REF*FJ*LINE1~
REF*CPT*27447~
DTP*368*D8*20240618~
CAT*AE*HL~
EFI*05~
BIN*150*VGhpcyBpcyBhIHNhbXBsZSBwYXlsb2Fk~

SE*14*0003~

Loop summary

For more information, please refer to 275 Additional Information to Support a Health Care Services Review_5010X211 3.pdf.

API Request Field → 275X211 Loop Crosswalk

Information source (Provider)

{
  "informationSource": {
    "npi": "1234567890",
    "name": "ABC Dental"
  }
}

Maps to

NM1*1P*2*ABC DENTAL*****XX*1234567890~

Payer information

{
  "payer": {
    "id": "87726",
    "name": "UnitedHealthcare"
  }
}

Maps to

NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~

Patient information

Prior Authorization information

Business data (sent to X12)

• priorAuthorizationNumber
• attachmentControlNumber
• serviceReviewTrackingNumber
• diagnosisCode
• procedureCode
• attachmentType
• document content

API metadata (not sent to X12)

• x-optum-consumer-correlation-id
• requestId
• environment
• timestamp
• gateway identifiers

API transport and correlation fields

📘

NOTE

The mapping of trackingNumber depends on the API implementation.
If the field serves as the attachment control number, it is mapped to TRN02.
If the field is used solely for API transaction tracking, it is not included in the 275 transaction.

Field classification

Clinical information

{
  "diagnosisCode": "K08.89",
  "*rocedureCode": "D4341",
  "loincCo*e": "27685-7"
}

Maps to

*TC*R4:27685-7::LOI~
REF**CD*K08.89~
REF*CPT*D4341~

Attachment metadata

Attachment content

Fields Not Translated into X12

📘

NOTE

Not every API field becomes an EDI segment. The 275X211 payload contains only the data required to support a health care services review request. API transport metadata (headers, correlation identifiers, timestamps, environment indicators, pagination attributes, etc.) are used by the API platform and are not included in the generated X12 transaction.

275x211 Prior Authorization data dictionary

Loop 1000A — Information Source

NM1*1P*2*ABC DENTAL*****XX*1234567890~
PER*IC*JOHN SMITH*TE*8005551212~

Loop 1000B — Information Receiver

NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~

Loop 1000C — Patient

NM1*QC*1*DOE*JANE****MI*987654321~
REF*EJ*12345~
REF*2I*EVT12345~

Loop 2000A — Attachment Detail

LX*1~
TRN*2*ATT123456~
STC*R4:27685-7::LOI~
REF*ICD*K08.89~
REF*CPT*D4341~
REF*FJ*ABC123~

Loop 2100A — Additional Information

Attachment type values

DTP*368*D8*20260825~
CAT*AE*IA~

Loop 2110A — Attachment Content

EFI*05~
BIN*5000*JVBERi0xLjQK...~

275X210 vs 275X211 mapping differences