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Sandbox Test Responses

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Receiver/Payer ID Test Responses

To assist testing your integration with the Prior Authorization Inquiry API, we have provided a number of test responses. To receive these mock responses, simply send your request body with a specific receiver/payer ID.

For X12 requests, set a specific value in the ISA:08 element.
For JSON requests, set a specific value in the payerId and umClearingHouseId field (same value in both fields).

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Important

The sandbox returns a canned response based on the receiver/payer ID. As such, these responses will not match the information in the request (i.e. different patients, services, etc. will be present in the response).

Below are the available test responses and their corresponding receiver/payer ID. If a payerId/clearinghouseId is sent that does not match one of the values below, an "Unable to Respond at Current Time/Payer Unavailable" response will be returned.

Receiver/Payer IDResponse
000000000000001Certified in total where subscriber is the patient
000000000000002Certified in total where dependent is the patient
000000000000003Authorization Number Not Found
000000000000004Unable to Respond at Current Time/Payer Unavailable

Member ID Test Responses

The responses for INQDEMO payer ID are based on the Member ID sent in the request. The Member ID needs to be one of the following values: TST1, TST2, TST3, TST4, TST5, TST6, TST7, TST8, TST9, TST10, or TST11.

Here the results that are returned for each of the above Member ID values:

Member ID = "TST1"
AuthNumber = "A062583941"
Status = "APPROVED"
PlaceofService = "inpatient"
Procedure Code = "58570"

Member ID = "TST2"
AuthNumber = "A062951774"
Status = "APPROVED"
PlaceofService = "inpatient"

Member ID = "TST3"
AuthNumber = "A060795810"
Status = "DENIED"
PlaceofService = "inpatient"
Procedure Code = "00170"

Member ID = "TST4"
AuthNumber = "A064331704"
Status = "PENDING"
PlaceofService = "inpatient"
Procedure Code = "52332"
Procedure Code = "52352"
Procedure Code = "52310"

Member ID = "TST5"
AuthNumber = "A062643861"
Status = "CANCELLED"
PlaceofService = "inpatient"
MSG = "WITHDRAWN"
Procedure Code = "20936", MSG = "WITHDRAWN"
Procedure Code = "22558", MSG = "WITHDRAWN"
Procedure Code = "22853", MSG = "WITHDRAWN"
Procedure Code = "22614", MSG = "WITHDRAWN"
Procedure Code = "22612", MSG = "WITHDRAWN"
Procedure Code = "63047", MSG = "WITHDRAWN"
Procedure Code = "22842", MSG = "WITHDRAWN"

Member ID = "TST6"
AuthNumber = "A063682496"
Status = "PARTIAL"
PlaceofService = "inpatient"
Procedure Code = "42145" Status = "DENIED"
Procedure Code = "42826" Status = "APPROVED"

Member ID = "TST7"
Status = "CONTACT PAYER"
MSG = "YOUR NOTIFICATION/PRIOR AUTHORIZATION SEARCH CANNOT BE COMPLETED ONLINE. PLEASE CALL THE NUMBER ON THE BACK OF THE MEMBER'S MEDICAL ID CARD"

Member ID = "TST8"
Status = "NO ACTION"
MSG = "PRODUCT DOES NOT HAVE NOTIFICATION REQUIREMENTS"

Member ID = "TST9"
Result = AUTHORIZATION_NOT_FOUND

Member ID = "TST10"
Result = NOTFOUND

Member ID = "TST11"
Result = INVALID_MISSING_DATA

Payload Examples

Prior Authorization Inquiry has two ways of submitting the payload (body of data) to our API--by x12 (EDI) and by JSON. See the following for examples on how to enter the request payload correctly for each.

x12 Example Request

{ "x12": "ISA*00* *00* *ZZ*943207296 *ZZ*000000000000001*230810*1021*^*00501*916040697*0*P*:~GS*HI*943207296*INQHEALTHHELP*20230810*102137*3294199*X*005010X215~ST*278*0001*005010X215~BHT*0007*28*1402448037*20230810*102137~HL*1**20*1~NM1*PR*2*Humana*****PI*HUMANA~HL*2*1*21*1~NM1*1P*2*North Memorial Health*****XX*1851344907~REF*EI*410729979~N4*Robbinsdale*MN*55422~PER*IC**TE*7635814480*FX*7635814480~HL*3*2*22*1~NM1*IL*1*DOE*JOE****MI*H1111111~REF*6P*00000000~DMG*D8*19010101~HL*4*3*EV*0~UM*HS*I*1*11:B~DTP*AAH*D8*20230802~HI*ABK:C34.32~NM1*SJ*2*North Memorial Medical Center*****XX*1851344907~NM1*DN*2*North Memorial Medical Center*****XX*1851344907~REF*ZH*410729979~SE*21*0001~GE*1*3294199~IEA*1*916040697~" }

Example Inquiry Request/Response

{ "senderId": "201985AAS", "submitterTransactionIdentifier": "1234567890", "payerId": "BCBSSC", "payerName": "South Carolina Blue Cross Blue", "umClearingHouseId": "000000000000001", "portalUsername": "portalUsername", "portalPassword": "portalPassword", "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 8 days ago