Prior Request/Authorization

Notes

• Payer must respond if request cancellation is not possible
• Payment Amount must have value and DenialCode must be empty if payer replies with trade drug for prescription request
• Authorization for EncounterType = 7 is not allowed (Network/encounter type access verification must be used instead)
• DenialCode is mandatory if Authorization.Result = No
• Must be empty for Activity.Type=10 [Generic drug], otherwise can have value
• IDPayer is mandatory if resubmission object is presented, otherwise must be empty
• Mandatory if request is approved or at least one activity is approved; optional otherwise
• See Business Rules 6.1 and 6.2 for observation requirements
• Effective 1 Jun 2013