Determination Response Body
{
"determination": {
"x12": "ISA*00* *00* *ZZ*000000000000001*ZZ*201985AAS *251114*1955*^*00501*669913763*0*P*:~GS*HI*BCBSSC*201985AAS*20251114*195553*669913763*X*005010X215~ST*278*669913763*005010X215~BHT*0007*49*1234567890*20251114*195553*18~HL*1**20*1~NM1*PR*2*South Carolina Blue Cross Blue*****PI*BCBSSC~HL*2*1*21*1~NM1*1P*2*Regional Medical Center*****XX*1234567890~REF*EI*123456789~HL*3*2*22*1~NM1*IL*1*TEST*BRITTANY****MI*ZCS12345678~REF*6P*123456789~REF*SY*111223333~DMG*D8*19701231~HL*4*3*EV*1~UM*HS*I*1*11:B~HCR*CT~DTP*AAH*RD8*20261017-20261017~NM1*SJ*1*TEST*STEVEN****XX*1234567890~NM1*DN*1*TEST*STEVEN****XX*1234567890~HL*5*4*SS*0~UM*HS***11:B~HCR*CT~DTP*472*RD8*20261017-20261017~SV1*HC:0200T~MSG*AUTHORIZATION IS REQUIRED FOR THIS PROCEDURE~HL*6*4*SS*0~UM*HS***11:B~HCR*NA~DTP*472*RD8*20231017-20231017~SV1*HC:74177~MSG*AUTHORIZATION IS NOT REQUIRED FOR THIS PROCEDURE~SE*31*669913763~GE*1*669913763~IEA*1*669913763~",
"json": {
"submitterTransactionIdentifier": "1234567890",
"payerId": "BCBSSC",
"payerName": "South Carolina Blue Cross Blue",
"umClearingHouseId": "201985AAS",
"umRequestValidation": null,
"requester": {
"requesterType": "1P",
"organizationName": "Regional Medical Center",
"requesterIdentification": {
"employerIdentificationNumber": "123456789"
},
"npi": "1234567890"
},
"subscriber": {
"lastName": "TEST",
"firstName": "BRITTANY",
"memberId": "ZCS12345678",
"dateOfBirth": "19701231",
"supplementalIdentification": {
"groupNumber": "123456789",
"ssn": "111223333"
}
},
"dependent": {
"supplementalIdentification": {}
},
"patientEventDetail": {
"requestCategoryCode": "HS",
"certificationTypeCode": "I",
"serviceTypeCode": "1",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"certificationActionCode": "CT",
"eventDateBegin": "20261017",
"eventDateEnd": "20261017",
"patientEventProviderName": [
{
"entityIdentifierCode": "SJ",
"lastName": "TEST",
"firstName": "STEVEN",
"identificationCodeQualifier": "XX",
"identifier": "1234567890",
"providerSupplementalInformation": {}
},
{
"entityIdentifierCode": "DN",
"lastName": "TEST",
"firstName": "STEVEN",
"identificationCodeQualifier": "XX",
"identifier": "1234567890",
"providerSupplementalInformation": {}
}
],
"serviceLevel": [
{
"requestCategoryCode": "HS",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"certificationActionCode": "CT",
"serviceDateBegin": "20261017",
"serviceDateEnd": "20261017",
"professionalService": {
"productOrServiceIDQualifier": "HC",
"procedureCode": "0200T"
},
"institutionalService": {},
"dentalService": {},
"freeFormMessageText": "AUTHORIZATION IS REQUIRED FOR THIS PROCEDURE"
},
{
"requestCategoryCode": "HS",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"certificationActionCode": "NA",
"serviceDateBegin": "20231017",
"serviceDateEnd": "20231017",
"professionalService": {
"productOrServiceIDQualifier": "HC",
"procedureCode": "74177"
},
"institutionalService": {},
"dentalService": {},
"freeFormMessageText": "AUTHORIZATION IS NOT REQUIRED FOR THIS PROCEDURE"
}
]
}
}
},
"determinationExceptions": [
{
"procedureCode": "0200T",
"exceptionDescription": "Precertification for this procedure may be required through a delegated organization for members in selected states. Check below for the appropriate contact information. Precertification may not apply to all areas or products available within the state. Please contact the vendor for details. Contact eviCore at 1-888-622-7329 except for states noted below*. *For Idaho (ID), Kentucky (KY) & Oregon (OR), call eviCore for commercial membership only. States noted below; call the number on the member?s ID card for precertification requirements: Hawaii (HI), Idaho (ID-Medicare only), Kentucky (KY-Medicare only), Minnesota (MN), North Dakota (ND), New Hampshire (NH), New Mexico (NM), Oregon (OR- Medicare only), Rhode Island (RI) Special situations"
},
{
"procedureCode": "74177"
}
]
}
{
"senderId": "201985AAS",
"submitterTransactionIdentifier": "1234567890",
"payerId": "BCBSSC",
"payerName": "South Carolina Blue Cross Blue",
"rhPayerId": "UHCDEMODV1",
"planId": "41",
"umClearingHouseId": "000000000000001",
"requester": {
"requesterType": "1P",
"organizationName": "Regional Medical Center",
"lastName": "Regional Medical Center",
"requesterIdentification": {
"employerIdentificationNumber": "123456789"
},
"city": "Orangeburg",
"state": "SC",
"postalCode": "12345",
"npi": "1234567890",
"contactTelephone": "803-395-2200"
},
"subscriber": {
"lastName": "TEST",
"firstName": "BRITTANY",
"memberId": "ZCS12345678",
"dateOfBirth": "19701231",
"supplementalIdentification": {
"groupNumber": "123456789",
"ssn": "111223333"
}
},
"patientEventDetail": {
"requestCategoryCode": "HS",
"certificationTypeCode": "I",
"serviceTypeCode": "1",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"eventDateBegin": "20231017",
"eventDateEnd": "20231017",
"patientEventProviderName": [
{
"entityIdentifierCode": "SJ",
"lastName": "TEST",
"firstName": "STEVEN",
"identificationCodeQualifier": "XX",
"identifier": "1234567890"
},
{
"entityIdentifierCode": "DN",
"lastName": "TEST",
"firstName": "STEVEN",
"identificationCodeQualifier": "XX",
"identifier": "1234567890"
}
],
"serviceLevel": [
{
"requestCategoryCode": "HS",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"serviceDateBegin": "20231017",
"serviceDateEnd": "20231017",
"professionalService": {
"productOrServiceIDQualifier": "HC",
"procedureCode": "71260"
}
},
{
"requestCategoryCode": "HS",
"facilityTypeCode": "11",
"facilityCodeQualifier": "B",
"serviceDateBegin": "20231017",
"serviceDateEnd": "20231017",
"professionalService": {
"productOrServiceIDQualifier": "HC",
"procedureCode": "74177"
}
}
]
}
}
Updated 19 days ago