NoA Response Body
{
"authorizationId": "c9f68aee-304b-4f1b-a0e9-95c9332d44a6",
"submission": {
"x12": "ISA*00* *00* *ZZ*OPTUM *ZZ*TPG30020006 *260203*0854*^*00501*897546880*0*P*:~GS*HI*MTEXE*LRX1210001*20260203*0755*897546880*X*005010X216~ST*278*897546880*005010X216~BHT*0007*53*222438911WEB*20260203*135456~HL*1**20*1~NM1*X3*2*PROHEALTH WAUKESHA MEMORIAL HOSPITAL*****XX*1629056890~HL*2*1*21*1~NM1*X3*2*AETNA*****PI*60054~HL*3*2*22*1~REF*BAF*9876543~NM1*IL*1*LASTNAME*FIRSTNAME*M***MI*12345678901~REF*6P*9876543~DMG*D8*19700101*F~HL*4*3*EV*0~UM*AR*I~SE*14*897546880~GE*1*897546880~IEA*1*897546880~",
"json": {
"submitterTransactionIdentifier": "222438911WEB",
"payerId": "60054",
"payerName": "AETNA",
"umClearingHouseId": "LRX1210001",
"receiverNotificationValidation": null,
"source": {
"sourceType": "X3",
"organizationName": "PROHEALTH WAUKESHA MEMORIAL HOSPITAL",
"sourceIdentification": {},
"npi": "1629056890"
},
"subscriber": {
"receiptNumber": "9876543",
"lastName": "LASTNAME",
"firstName": "FIRSTNAME",
"middleName": "M",
"memberId": "12345678901",
"dateOfBirth": "19700101",
"genderCode": "F",
"supplementalIdentification": {
"groupNumber": "9876543"
}
},
"dependent": {
"supplementalIdentification": {}
},
"patientEventDetail": {
"requestCategoryCode": "AR",
"certificationTypeCode": "I"
}
}
}
}
Updated about 13 hours ago