NoA Request Body
{
"senderId": "201985AAS",
"submitterTransactionIdentifier": "BHT03",
"payerId": "2010B NM109 NM101=PR NM102=2 - If UMClearingHouseID is empty populate also ISA08 GS03",
"payerName": "2010B NM103",
"umClearingHouseId": "if not empty populate ISA08 GS03",
"source": {
"sourceType": "2010A NM101 Default 1P",
"organizationName": "2010A NM103 NM102=2",
"lastName": "2010A NM103",
"firstName": "2010A NM104 NM102=1",
"middleName": "2010A NM105",
"suffixName": "2010A NM107",
"sourceIdentification": {
"providerUpinNumber": "2010A REF02 REF01=1G",
"facilityIdNumber": "2010A REF02 REF01=1J",
"employerIdentificationNumber": "2010A REF02 REF01=EI",
"providerSiteNumber": "2010A REF02 REF01=G5",
"providerPlanNetworkIdNumber": "2010A REF02 REF01=N5",
"facilityNetworkIdNumber": "2010A REF02 REF01=N7",
"socialSecurityNumber": "2010A REF02 REF01=SY",
"carrierAssignedReferenceNumber": "2010A REF02 REF01=ZH"
},
"address1": "2010A N301",
"address2": "2010A N302",
"city": "2010A N401",
"state": "2010A N402",
"postalCode": "2010A N403",
"countryCode": "2010A N404",
"countrySubDivisionCode": "2010A N407",
"npi": "2010A NM109 NM108=XX",
"payorId": "2010A NM109 NM108=PI",
"ssn": "2010A NM109 NM108=34",
"servicesPlanID": "2010A NM109 NM108=XV",
"employersId": "2010A NM109 NM108=24",
"etin": "2010A NM109 NM108=46",
"contactName": "2010A PER02 PER01=IC",
"contactElectronicMail": "2010A PER04 PER03=EM or PER06 PER05=EM or PER08 PER07=EM",
"contactFacsimile": "2010A PER04 PER03=FX or PER06 PER05=FX or PER08 PER07=FX",
"contactTelephone": "2010A PER04 PER03=TE or PER06 PER05=TE or PER08 PER07=TE",
"providerCode": "2010A PRV01 PRV02=PXC",
"referenceIdentification": "2010A PRV03"
},
"subscriber": {
"lastName": "2010C NM103 NM101=IL NM102=1",
"firstName": "2010C NM104",
"middleName": "2010C NM105",
"suffix": "2010C NM107",
"memberId": "2010C NM109 NM108=MI",
"supplementalIdentification": {
"policyNumber": "2010C REF02 REF01=1L",
"groupNumber": "2010C REF02 REF01=6P",
"patientAccountNumber": "2010C REF02 REF01=EJ",
"healthInsuranceClaimNumber": "2010C REF02 REF01=F6",
"idCard": "2010C REF02 REF01=HJ",
"insurancePolicyNumber": "2010C REF02 REF01=IG",
"planNetworkIdentificationNumber": "2010C REF02 REF01=N6",
"medicaidRecipientIdentificationNumber": "2010C REF02 REF01=NQ",
"ssn": "2010C REF02 REF01=SY"
},
"address1": "2010C N301",
"address2": "2010C N302",
"city": "2010C N401",
"state": "2010C N402",
"postalCode": "2010C N403",
"countryCode": "2010C N404",
"countrySubDivisionCode": "2010C N407",
"dateOfBirth": "2010C DMG02 DMG01=D8 YYYYMMDD",
"genderCode": "2010C DMG03",
"militaryRelationship": "2010C INS08"
},
"dependent": {
"lastName": "2010D NM103 NM101=QC NM102=1",
"firstName": "2010D NM104",
"middleName": "2010D NM105",
"suffix": "2010D NM107",
"dateOfBirth": "2010D DMG02 DMG01=D8 YYYYMMDD",
"genderCode": "2010D DMG03",
"supplementalIdentification": {
"patientAccountNumber": "2010D REF02 REF01=EJ",
"ssn": "2010D REF02 REF01=SY"
},
"address1": "2010D N301",
"address2": "2010D N302",
"city": "2010D N401",
"state": "2010D N402",
"postalCode": "2010D N403",
"countryCode": "2010D N404",
"countrySubDivisionCode": "2010D N407",
"relationshipToInsuredCode": "2010D INS02 INS01=N",
"birthSequenceNumber": "2010D INS17"
},
"patientEventDetail": {
"requestCategoryCode": "2000E UM01",
"certificationTypeCode": "2000E UM02",
"serviceTypeCode": "2000E UM03",
"facilityTypeCode": "2000E UM04_1",
"facilityCodeQualifier": "2000E UM04_2",
"levelOfServiceCode": "2000E UM06",
"certificationActionCode": "2000E HCR01",
"reviewIdentificationNumber": "2000E HCR02",
"reviewDecisionReasonCode": "2000E HCR03",
"secondSurgicalOpinionIndicator": "2000E HCR04",
"previousReviewAuthorizationNumber": "2000E REF02 REF01=BB",
"previousAdministrativeReferenceNumber": "2000E REF02 REF01=NT",
"accidentDate": "2000E DTP03 DTP01=439 DTP02=D8 YYYYMMDD",
"lastMenstrualPeriodDate": "2000E DTP03 DTP01=484 DTP02=D8 YYYYMMDD",
"estimatedDateOfBirth": "2000E DTP03 DTP01=ABC DTP02=D8 YYYYMMDD",
"onsetDate": "2000E DTP03 DTP01=431 DTP02=D8 YYYYMMDD",
"eventDateBegin": "2000E DTP03 DTP01=AAH DTP02=D8 YYYYMMDD",
"eventDateEnd": "2000E DTP03 DTP01=AAH DTP02=RD8 YYYYMMDD EventDateBegin must exist",
"admissionDateBegin": "2000E DTP03 DTP01=435 DTP02=D8 YYYYMMDD",
"admissionDateEnd": "2000E DTP03 DTP01=435 DTP02=RD8 YYYYMMDD AdmissionDateBegin must exist",
"dischargeDate": "2000E DTP03 DTP01=096 DTP02=D8 YYYYMMDD",
"certificationIssueDateBegin": "2000E DTP03 DTP01=102 DTP02=D8 YYYYMMDD",
"certificationIssueDateEnd": "2000E DTP03 DTP01=102 DTP02=RD8 YYYYMMDD CertificationIssueDateBegin must exist",
"certificationExpirationDateBegin": "2000E DTP03 DTP01=036 DTP02=D8 YYYYMMDD",
"certificationExpirationDateEnd": "2000E DTP03 DTP01=036 DTP02=RD8 YYYYMMDD CertificationExpirationDateBegin must exist",
"certificationEffectiveDateBegin": "2000E DTP03 DTP01=007 DTP02=D8 YYYYMMDD",
"certificationEffectiveDateEnd": "2000E DTP03 DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist",
"diagnosisTypeCode1": "2000E HI01_1",
"diagnosisCode1": "2000E HI01_2",
"diagnosisDate1": "2000E HI01_4 HI01_3=D8 YYYYMMDD",
"diagnosisTypeCode2": "2000E HI02_1",
"diagnosisCode2": "2000E HI02_2",
"diagnosisDate2": "2000E HI02_4 HI02_3=D8 YYYYMMDD",
"diagnosisTypeCode3": "2000E HI03_1",
"diagnosisCode3": "2000E HI03_2",
"diagnosisDate3": "2000E HI03_4 HI03_3=D8 YYYYMMDD",
"diagnosisTypeCode4": "2000E HI04_1",
"diagnosisCode4": "2000E HI04_2",
"diagnosisDate4": "2000E HI04_4 HI04_3=D8 YYYYMMDD",
"diagnosisTypeCode5": "2000E HI05_1",
"diagnosisCode5": "2000E HI05_2",
"diagnosisDate5": "2000E HI05_4 HI05_3=D8 YYYYMMDD",
"diagnosisTypeCode6": "2000E HI06_1",
"diagnosisCode6": "2000E HI06_2",
"diagnosisDate6": "2000E HI06_4 HI06_3=D8 YYYYMMDD",
"diagnosisTypeCode7": "2000E HI07_1",
"diagnosisCode7": "2000E HI07_2",
"diagnosisDate7": "2000E HI07_4 HI07_3=D8 YYYYMMDD",
"diagnosisTypeCode8": "2000E HI08_1",
"diagnosisCode8": "2000E HI08_2",
"diagnosisDate8": "2000E HI08_4 HI08_3=D8 YYYYMMDD",
"diagnosisTypeCode9": "2000E HI09_1",
"diagnosisCode9": "2000E HI09_2",
"diagnosisDate9": "2000E HI09_4 HI09_3=D8 YYYYMMDD",
"diagnosisTypeCode10": "2000E HI010_1",
"diagnosisCode10": "2000E HI010_2",
"diagnosisDate10": "2000E HI010_4 HI010_3=D8 YYYYMMDD",
"diagnosisTypeCode11": "2000E HI011_1",
"diagnosisCode11": "2000E HI011_2",
"diagnosisDate11": "2000E HI011_4 HI011_3=D8 YYYYMMDD",
"diagnosisTypeCode12": "2000E HI012_1",
"diagnosisCode12": "2000E HI012_2",
"diagnosisDate12": "2000E HI012_4 HI012_3=D8 YYYYMMDD",
"quantityQualifier": "2000E HSD01",
"serviceUnitCount": "2000E HSD02",
"unitOrBasisForMeasurementCode": "2000E HSD03",
"sampleSelectionModulus": "2000E HSD04",
"timePeriodQualifier": "2000E HSD05",
"periodCount": "2000E HSD06",
"deliveryFrequencyCode": "2000E HSD07",
"deliveryPatternTimeCode": "2000E HSD08",
"admissionToFacility": {
"admissionTypeCode": "2000E CL101",
"admissionSourceCode": "2000E CL102",
"patientStatusCode": "2000E CL103"
},
"ambulanceTransport": {
"transportCode": "2000E CR103",
"transportDistance": "2000E CR106 CR105=DH"
},
"spinalManipulation": {
"treatmentSeriesNumber": "2000E CR201",
"treatmentCount": "2000E CR202",
"subluxationBeginningLevelCode": "2000E CR203",
"subluxationEndLevelCode": "2000E CR204"
},
"homeOxygenTherapyInformation": {
"equipmentTypeCode1": "2000E CR503",
"equipmentTypeCode2": "2000E CR504",
"equipmentTypeCode3": "2000E CR518",
"flowRate": "2000E CR506",
"dailyUseCount": "2000E CR507",
"usePeriodHourCount": "2000E CR508",
"respiratoryTherapistOrderText": "2000E CR509",
"portableSystemFlowRate": "2000E CR516",
"deliverySystemCode": "2000E CR517"
},
"homeHealth": {
"prognosisCode": "2000E CR601",
"startDate": "2000E CR602",
"certificationPeriodStartDate": "2000E CR604",
"certificationPeriodEndDate": "2000E CR604 CR603=RD8",
"medicareCoverageIndicator": "2000E CR607",
"certificationTypeCode": "2000E CR608"
},
"attachments": [
{
"reportTypeCode": "2000E PWK01",
"transmissionCode": "2000E PWK02",
"controlNumber": "2000E PWK06 PWK05=AC",
"description": "2000E PWK07"
}
],
"freeFormMessageText": "2000E MSG01",
"patientEventProviderName": [
{
"entityIdentifierCode": "2010EA NM101",
"organizationName": "2010EA NM103 NM102=2",
"lastName": "2010EA NM103",
"firstName": "2010EA NM104 NM102=1",
"middleName": "2010EA NM105",
"namePrefix": "2010EA NM106",
"nameSuffix": "2010EA NM107",
"identificationCodeQualifier": "2010EA NM108",
"identifier": "2010EA NM109",
"address1": "2010EA N301",
"address2": "2010EA N302",
"city": "2010EA N401",
"state": "2010EA N402",
"postalCode": "2010EA N403",
"countryCode": "2010EA N404",
"countrySubDivisionCode": "2010EA N407",
"providerSupplementalInformation": {
"stateLicenseNumber": "2010EA REF02 REF01=0B",
"licenseNumberStateCode": "2010EA REF03 Required if StateLicenseNumber is entered",
"providerUpinNumber": "2010EA REF02 REF01=1G",
"facilityIdNumber": "2010EA REF02 REF01=1J",
"employersIdentificationNumber": "2010EA REF02 REF01=EI",
"providerPlanNetworkIdentificationNumber": "2010EA REF02 REF01=N5",
"facilityNetworkIdentificationNumber": "2010EA REF02 REF01=N7",
"ssn": "2010EA REF02 REF01=SY",
"carrierAssignedReferenceNumber": "2010EA REF02 REF01=ZH"
},
"contactName": "2010EA PER02 PER01=IC",
"contactElectronicMail": "2010EA PER04 PER03=EM or PER06 PER05=EM or PER08 PER07=EM",
"contactFacsimile": "2010EA PER04 PER03=FX or PER06 PER05=FX or PER08 PER07=FX",
"contactTelephone": "2010EA PER04 PER03=TE or PER06 PER05=TE or PER08 PER07=TE",
"providerCode": "2010EA PRV01 PRV02=PXC",
"providerTaxonomyCode": "2010EA PRV03"
}
],
"additionalPatientInformationContactName": [
{
"entityIdentifierCode": "2010EB NM101=L5",
"organizationName": "2010EB NM103 NM102=2",
"lastName": "2010EB NM103",
"firstName": "2010EB NM104 NM102=1",
"middleName": "2010EB NM105",
"nameSuffix": "2010EB NM107",
"identificationCodeQualifier": "2010EB NM108",
"identifier": "2010EB NM109",
"address1": "2010EB N301",
"address2": "2010EB N302",
"city": "2010EB N401",
"state": "2010EB N402",
"postalCode": "2010EB N403",
"countryCode": "2010EB N404",
"countrySubDivisionCode": "2010EB N407",
"contactName": "2010EB PER02 PER01=IC",
"contactElectronicMail": "2010EB PER04 PER03=EM or PER06 PER05=EM or PER08 PER07=EM",
"contactFacsimile": "2010EB PER04 PER03=FX or PER06 PER05=FX or PER08 PER07=FX",
"contactTelephone": "2010EB PER04 PER03=TE or PER06 PER05=TE or PER08 PER07=TE"
}
],
"patientEventTransportInformation": [
{
"entityIdentifierCode": "2010EC NM101",
"transportLocationName": "2010EC NM103 NM102=2",
"address1": "2010EC N301",
"address2": "2010EC N302",
"city": "2010EC N401",
"state": "2010EC N402",
"postalCode": "2010EC N403"
}
],
"patientEventOtherUmoName": [
{
"entityIdentifierCode": "2010ED NM101",
"otherUmoName": "2010ED NM103 NM102=2",
"otherUmoDenialReason1": "2010ED REF02 REF01=ZZ",
"otherUmoDenialReason2": "2010ED REF04_2 REF04_1=ZZ",
"otherUmoDenialReason3": "2010ED REF04_4 REF04_3=ZZ",
"otherUmoDenialReason4": "2010ED REF04_6 REF04_5=ZZ",
"otherUmoDenialDate": "2010ED DTP03 YYYYMMDD DTP01=598 DTP02=D8"
}
],
"serviceLevel": [
{
"requestCategoryCode": "2000F UM01",
"certificationTypeCode": "2000F UM02",
"serviceTypeCode": "2000F UM03",
"facilityTypeCode": "2000F UM04_1",
"facilityCodeQualifier": "2000F UM04_2",
"certificationActionCode": "2000F HCR01",
"reviewIdentificationNumber": "2000F HCR02",
"reviewDecisionReasonCode": "2000F HCR03",
"secondSurgicalOpinionIndicator": "2000F HCR04",
"previousReviewAuthorizationNumber": "2000F REF02 REF01=BB",
"previousAdministrativeReferenceNumber": "2000F REF02 REF01=NT",
"serviceDateBegin": "2000F DTP03 DTP01=472 DTP02=D8 YYYYMMDD",
"serviceDateEnd": "2000F DTP03 DTP01=472 DTP02=RD8 YYYYMMDD ServiceDateBegin must exist",
"certificationIssueDate": "2000F DTP03 DTP01=102 DTP02=D8 YYYYMMDD",
"certificationExpirationDate": "2000F DTP03 DTP01=036 DTP02=D8 YYYYMMDD",
"certificationEffectiveDateBegin": "2000F DTP03 DTP01=007 DTP02=D8 YYYYMMDD",
"certificationEffectiveDateEnd": "2000F DTP03 DTP01=007 DTP02=RD8 YYYYMMDD CertificationEffectiveDateBegin must exist",
"professionalService": {
"productOrServiceIDQualifier": "2000F SV101_1",
"procedureCode": "2000F SV101_2",
"procedureModifier1": "2000F SV101_3",
"procedureModifier2": "2000F SV101_4",
"procedureModifier3": "2000F SV101_5",
"procedureModifier4": "2000F SV101_6",
"procedureCodeDescription": "2000F SV101_7",
"procedureCode2": "2000F SV101_8",
"serviceLineAmount": "2000F SV102",
"unitOrBasisForMeasurementCode": "2000F SV103",
"serviceUnitCount": "2000F SV104",
"diagnosisCodePointer1": "2000F SV107_1",
"diagnosisCodePointer2": "2000F SV107_2",
"diagnosisCodePointer3": "2000F SV107_3",
"diagnosisCodePointer4": "2000F SV108_4",
"epsdtIndicator": "2000F SV111",
"nursingHomeLevelOfCare": "2000F SV120"
},
"institutionalService": {
"serviceLineRevenueCode": "2000F SV201",
"productOrServiceIDQualifier": "2000F SV202_1",
"procedureCode": "2000F SV202_2",
"procedureModifier1": "2000F SV202_3",
"procedureModifier2": "2000F SV202_4",
"procedureModifier3": "2000F SV202_5",
"procedureModifier4": "2000F SV202_6",
"procedureCodeDescription": "2000F SV202_7",
"procedureCode2": "2000F SV202_8",
"serviceLineAmount": "2000F SV203",
"unitOrBasisForMeasurementCode": "2000F SV204",
"serviceUnitCount": "2000F SV205",
"serviceLineRate": "2000F SV206",
"nursingHomeResidentialStatusCode": "2000F SV209",
"nursingHomeLevelOfCare": "2000F SV210"
},
"dentalService": {
"procedureCode": "2000F SV301_2 SV301_1=AD",
"procedureModifier1": "2000F SV301_3",
"procedureModifier2": "2000F SV301_4",
"procedureModifier3": "2000F SV301_5",
"procedureModifier4": "2000F SV301_6",
"procedureCodeDescription": "2000F SV301_7",
"procedureCode2": "2000F SV301_8",
"serviceLineAmount": "2000F SV302",
"oralCavityDesignationCode": "2000F SV304_1",
"oralCavityDesignationCode2": "2000F SV304_2",
"oralCavityDesignationCode3": "2000F SV304_3",
"oralCavityDesignationCode4": "2000F SV304_4",
"oralCavityDesignationCode5": "2000F SV304_5",
"prosthesisCrownOrInlayCode": "2000F SV305",
"serviceUnitCount": "2000F SV306",
"description": "2000F SV307"
},
"toothInformation": [
{
"toothCode": "2000F TOO02 TOO01=JP",
"toothSurfaceCode1": "2000F TOO03_1",
"toothSurfaceCode2": "2000F TOO03_2",
"toothSurfaceCode3": "2000F TOO03_3",
"toothSurfaceCode4": "2000F TOO03_4",
"toothSurfaceCode5": "2000F TOO03_5"
}
],
"healthCareServiceDelivery": {
"quantityQualifier": "2000F HSD01",
"serviceQuantity": "2000F HSD02",
"unitOrBasisForMeasurementCode": "2000F HSD03",
"sampleSelectionModulus": "2000F HSD04",
"timePeriodQualifier": "2000F HSD05",
"periodCount": "2000F HSD06",
"deliveryFrequencyCode": "2000F HSD07",
"deliveryPatternTimeCode": "2000F HSD08"
},
"attachments": [
{
"reportTypeCode": "2000F PWK01",
"transmissionCode": "2000F PWK02",
"controlNumber": "2000F PWK06 PWK05=AC",
"description": "2000F PWK07"
}
],
"freeFormMessageText": "2000F MSG01",
"serviceProviderName": [
{
"entityIdentifierCode": "2010F NM101",
"organizationName": "2010F NM103 NM102=2",
"lastName": "2010F NM103",
"firstName": "2010F NM104 NM102=1",
"middleName": "2010F NM105",
"namePrefix": "2010F NM106",
"nameSuffix": "2010F NM107",
"identificationCodeQualifier": "2010F NM108",
"identifier": "2010F NM109",
"address1": "2010F N301",
"address2": "2010F N302",
"city": "2010F N401",
"state": "2010F N402",
"postalCode": "2010F N403",
"countryCode": "2010F N404",
"countrySubDivisionCode": "2010F N407",
"providerSupplementalInformation": {
"stateLicenseNumber": "2010F REF02 REF01=0B",
"licenseNumberStateCode": "2010F REF03 Required if StateLicenseNumber is entered",
"providerUpinNumber": "2010F REF02 REF01=1G",
"facilityIdNumber": "2010F REF02 REF01=1J",
"employersIdentificationNumber": "2010F REF02 REF01=EI",
"providerSiteNumber": "2010F REF02 REF01=G5",
"providerPlanNetworkIdentificationNumber": "2010F REF02 REF01=N5",
"facilityNetworkIdentificationNumber": "2010F REF02 REF01=N7",
"ssn": "2010F REF02 REF01=SY",
"carrierAssignedReferenceNumber": "2010F REF02 REF01=ZH"
},
"contactName": "2010F PER02 PER01=IC",
"contactElectronicMail": "2010F PER04 PER03=EM or PER06 PER05=EM or PER08 PER07=EM",
"contactFacsimile": "2010F PER04 PER03=FX or PER06 PER05=FX or PER08 PER07=FX",
"contactTelephone": "2010F PER04 PER03=TE or PER06 PER05=TE or PER08 PER07=TE",
"providerCode": "2010F PRV01 PRV02=PXC",
"providerTaxonomyCode": "2010F PRV03"
}
]
}
]
}
}
Updated about 13 hours ago