Submission Response Body
{
"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"
}
]
}
}
}
}
{
"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": {
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"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",
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},
{
"entityIdentifierCode": "DN",
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"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"
}
]
}
}
}
}
Updated 21 days ago