Submission Response Body

  • Example submission response with Subscriber only
{ "authorizationId": "a14081f3-b463-449e-a9dc-7ee21aef4552", "submission": { "x12": "ISA*00* *00* *ZZ*INQMEDSOLUTIONS*ZZ*123456789 *240220*2059*^*00501*709893603*0*P*:~GS*HI*INQMEDSOLUTIONS*123456789*20240220*205925*148363198*X*005010X215~ST*278*0001*005010X215~BHT*0007*49*1234567890*20240220*205925*RD~HL*1**20*1~NM1*PR*2*MEDSOLUTIONS*****PI*CIGNA~PER*IC**UR*https//www.evicore.com/provider#login~HL*2*1*21*1~NM1*1P*2*WESTCHESTER MEDICAL CENTER*****XX*1234567890~REF*EI*123456789~HL*3*2*22*1~NM1*IL*1*SMITH*TOM****MI* U1234567890~REF*SY*123121234~REF*3L*12345-1702~REF*1L*CIGNA SI-PPO/OAP~N3*SOME ROAD~N4*BEDFORD*NY*12345~DMG*D8*19700101~HL*4*3*EV*1~HCR*A1*A12345678~REF*BB*A12345678~REF*NT*52598960~DTP*102*D8*20240220~DTP*036*D8*20240818~DTP*007*D8*20240220~DTP*881*D8*20240220~HI*ABK:R07.9~MSG*APPROVED~NM1*FA*2*TEST, DOMINICA*****XX*1234567890~N3*100 DEMO RD~N4*VALHALLA*NY*12345~PER*IC**TE*2223334444*FX*1112223333~NM1*DN*1*TEST*DOMINICA****XX*1234567890~N3*100 DEMO RD~N4*VALHALLA*NY*12345~PER*IC**TE*3334445555~HL*5*4*SS*0~HCR*A1*A12345678~SV1*HC:78452**UN*1~MSG*MYOCARDIAL PERFUSION IMAGING (SPECT); MULTIPLE STUDIES~SE*39*0001~GE*1*148363198~IEA*1*709893603~", "json": { "submitterTransactionIdentifier": "1234567890", "payerId": "CIGNA", "payerName": "MEDSOLUTIONS", "umClearingHouseId": "123456789", "contactUrl": "https//www.evicore.com/provider#login", "umRequestValidation": null, "requester": { "requesterType": "1P", "organizationName": "WESTCHESTER MEDICAL CENTER", "requesterIdentification": { "employerIdentificationNumber": "123456789" }, "npi": "1234567890" }, "subscriber": { "lastName": "SMITH", "firstName": "TOM", "memberId": " U1234567890", "dateOfBirth": "19700101", "address1": "SOME ROAD", "city": "BEDFORD", "state": "NY", "postalCode": "12345", "supplementalIdentification": { "policyNumber": "CIGNA SI-PPO/OAP", "branchIdentifier": "12345-1702", "ssn": "123121234" } }, "patientEventDetail": { "certificationActionCode": "A1", "reviewIdentificationNumber": "A12345678", "previousReviewAuthorizationNumber": "A12345678", "previousAdministrativeReferenceNumber": "52598960", "certificationIssueDate": "20240220", "certificationExpirationDate": "20240818", "certificationEffectiveDateBegin": "20240220", "healthCareServicesReviewRequestDateBegin": "20240220", "diagnosisTypeCode": "ABK", "diagnosisCode": "R07.9", "freeFormMessageText": "APPROVED", "patientEventProviderName": [ { "entityIdentifierCode": "FA", "organizationName": "TEST, DOMINICA", "identificationCodeQualifier": "XX", "identifier": "1234567890", "address1": "100 DEMO RD", "city": "VALHALLA", "state": "NY", "postalCode": "12345", "providerSupplementalInformation": {}, "contactFacsimile": "1112223333", "contactTelephone": "2223334444" }, { "entityIdentifierCode": "DN", "lastName": "TEST", "firstName": "DOMINICA", "identificationCodeQualifier": "XX", "identifier": "1234567890", "address1": "100 DEMO RD", "city": "VALHALLA", "state": "NY", "postalCode": "12345", "providerSupplementalInformation": {}, "contactTelephone": "3334445555" } ], "serviceLevel": [ { "certificationActionCode": "A1", "reviewIdentificationNumber": "A12345678", "professionalService": { "productOrServiceIDQualifier": "HC", "procedureCode": "78452", "unitOrBasisForMeasurementCode": "UN", "serviceUnitCount": "1" }, "institutionalService": {}, "dentalService": {}, "freeFormMessageText": "MYOCARDIAL PERFUSION IMAGING (SPECT); MULTIPLE STUDIES" } ] } } } }
  • Example submission response with dependent
{ "authorizationId": "a14081f3-b463-449e-a9dc-7ee21aef4552", "submission": { "x12": "ISA*00* *00* *ZZ*INQMEDSOLUTIONS*ZZ*123456789 *240220*2059*^*00501*709893603*0*P*:~GS*HI*INQMEDSOLUTIONS*123456789*20240220*205925*148363198*X*005010X215~ST*278*0001*005010X215~BHT*0007*49*1234567890*20240220*205925*RD~HL*1**20*1~NM1*PR*2*MEDSOLUTIONS*****PI*CIGNA~PER*IC**UR*https//www.evicore.com/provider#login~HL*2*1*21*1~NM1*1P*2*WESTCHESTER MEDICAL CENTER*****XX*1234567890~REF*EI*123456789~HL*3*2*22*1~NM1*IL*1*SMITH*TOM****MI* U1234567890~REF*SY*123121234~REF*3L*12345-1702~REF*1L*CIGNA SI-PPO/OAP~N3*SOME ROAD~N4*BEDFORD*NY*12345~DMG*D8*19700101~HL*4*3*EV*1~HCR*A1*A12345678~REF*BB*A12345678~REF*NT*52598960~DTP*102*D8*20240220~DTP*036*D8*20240818~DTP*007*D8*20240220~DTP*881*D8*20240220~HI*ABK:R07.9~MSG*APPROVED~NM1*FA*2*TEST, DOMINICA*****XX*1234567890~N3*100 DEMO RD~N4*VALHALLA*NY*12345~PER*IC**TE*2223334444*FX*1112223333~NM1*DN*1*TEST*DOMINICA****XX*1234567890~N3*100 DEMO RD~N4*VALHALLA*NY*12345~PER*IC**TE*3334445555~HL*5*4*SS*0~HCR*A1*A12345678~SV1*HC:78452**UN*1~MSG*MYOCARDIAL PERFUSION IMAGING (SPECT); MULTIPLE STUDIES~SE*39*0001~GE*1*148363198~IEA*1*709893603~", "json": { "submitterTransactionIdentifier": "1234567890", "payerId": "CIGNA", "payerName": "MEDSOLUTIONS", "umClearingHouseId": "123456789", "contactUrl": "https//www.evicore.com/provider#login", "umRequestValidation": null, "requester": { "requesterType": "1P", "organizationName": "WESTCHESTER MEDICAL CENTER", "requesterIdentification": { "employerIdentificationNumber": "123456789" }, "npi": "1234567890" }, "subscriber": { "lastName": "SMITH", "firstName": "TOM", "memberId": " U1234567890", "dateOfBirth": "19700101", "address1": "SOME ROAD", "city": "BEDFORD", "state": "NY", "postalCode": "12345", "supplementalIdentification": { "policyNumber": "CIGNA SI-PPO/OAP", "branchIdentifier": "12345-1702", "ssn": "123121234" } }, "dependent": { "lastName": "SMITH", "firstName": "JANE", "dateOfBirth": "19700101", "address1": "SOME ROAD", "city": "BEDFORD", "state": "NY", "postalCode": "12345", "supplementalIdentification": { "ssn": "123984321" } }, "patientEventDetail": { "certificationActionCode": "A1", "reviewIdentificationNumber": "A12345678", "previousReviewAuthorizationNumber": "A12345678", "previousAdministrativeReferenceNumber": "52598960", "certificationIssueDate": "20240220", "certificationExpirationDate": "20240818", "certificationEffectiveDateBegin": "20240220", "healthCareServicesReviewRequestDateBegin": "20240220", "diagnosisTypeCode": "ABK", "diagnosisCode": "R07.9", "freeFormMessageText": "APPROVED", "patientEventProviderName": [ { "entityIdentifierCode": "FA", "organizationName": "TEST, DOMINICA", "identificationCodeQualifier": "XX", "identifier": "1234567890", "address1": "100 DEMO RD", "city": "VALHALLA", "state": "NY", "postalCode": "12345", "providerSupplementalInformation": {}, "contactFacsimile": "1112223333", "contactTelephone": "2223334444" }, { "entityIdentifierCode": "DN", "lastName": "TEST", "firstName": "DOMINICA", "identificationCodeQualifier": "XX", "identifier": "1234567890", "address1": "100 DEMO RD", "city": "VALHALLA", "state": "NY", "postalCode": "12345", "providerSupplementalInformation": {}, "contactTelephone": "3334445555" } ], "serviceLevel": [ { "certificationActionCode": "A1", "reviewIdentificationNumber": "A12345678", "professionalService": { "productOrServiceIDQualifier": "HC", "procedureCode": "78452", "unitOrBasisForMeasurementCode": "UN", "serviceUnitCount": "1" }, "institutionalService": {}, "dentalService": {}, "freeFormMessageText": "MYOCARDIAL PERFUSION IMAGING (SPECT); MULTIPLE STUDIES" } ] } } } }