Authorization File Data Elements

The Extract Identifier code for this file is PA.

 

Refer to Appendix B, “Authorization Data-Map Process,” for details on how Authorization records are added or updated in the Healthx database.

 

Field

Field Name

Req.

Len

Type

Notes

1

VersionNumber

K

10

AN

Spec Version Number: 3.04

2

MemberID

R

64

AN

Member’s ID Number

3

GroupNumber

R

20

AN

Member’s Group ID Number

4

LastName

R

50

AN

Member’s Last Name

5

FirstName

R

50

AN

Member’s First Name

6

PatientID

R

64

AN

ID # of the Patient (from their ID card)

7

PTName

R

50

AN

Patient’s Name

8

PTDOB

R

8

DT

Patient’s Date of Birth

9

PCPID

O

20

AN

Patient’s Primary Care Physician ID

10

PCPName

O

100

AN

Patient’s Primary Care Physician Name

11

AuthType

R

50

AN

Type of Authorization

12

AuthDecision

R

255

AN

Denial/Approval decision for Authorization

13

AuthNumber

K

64

AN

Pre-certification/Referral Number

14

Rationale

R

255

AN

Reason for Service

15

RequestDate

R

8

DT

Date of Request or Notification

16

OrgProviderID

R

100

AN

This is a value that uniquely identifies the provider and is used in the HealthPlan Provider Portal to tie all provider data together. It can be an NPI, UPIN, or any other value that uniquely identifies the provider for your organization.  It should be a value the provider knows.

17

MasterTIN

O

12

AN

Master Provider TIN


Field #

Field Name

Req.

Len

Type

Notes

18

ProviderName

R

255

AN

Provider of Service’s Name

19

ProviderID

O

64

AN

Claim System Internal ID for the Provider

20

PhysicianID

O

64

AN

Assigned Provider ID

21

NPIN

R

10

AN

National Provider ID

22

ProviderTIN

K

12

AN

Tax ID Number

23

ProviderTINSuffix

R

10

AN

Tax ID Suffix

24

DOSStart

R

8

DT

Date of Service/Begin Date

25

DOSEnd

R

8

DT

Approved Through/End Date

26

HCPCS1

R

5

AN

HCPCS Procedure Code

27

HCPCS1Desc

R

255

AN

HCPCS Procedure Code Description

28

Units1

R

12

NU

Units/Quantity

29

HCPCS2

R

5

AN

HCPCS Procedure Code - Addtl

30

HCPCS2Desc

R

255

AN

HCPCS Procedure Code Description

31

Units2

R

12

NU

Units/Quantity

32

HCPCS3

R

5

AN

HCPCS Procedure Code – Addtl

33

HCPCS3Desc

R

255

AN

HCPCS Procedure Code Description

34

Units3

R

12

NU

Units/Quantity

35

HCPCS4

R

5

AN

HCPCS Procedure Code – Addtl

36

HCPCS4Desc

R

255

AN

HCPCS Procedure Code Description

37

Units4

R

12

NU

Units/Quantity

38

HCPCS5

R

5

AN

HCPCS Procedure Code – Addtl

39

HCPCS5Desc

R

255

AN

HCPCS Procedure Code Description

40

Units5

R

12

NU

Units/Quantity

41

HCPCS6

R

5

AN

HCPCS Procedure Code

42

HCPCS6Desc

R

255

AN

HCPCS Procedure Code Description

43

Units6

R

12

NU

Units/Quantity

44

HCPCS7

R

5

AN

HCPCS Procedure Code - Addtl

45

HCPCS7Desc

R

255

AN

HCPCS Procedure Code Description

46

Units7

R

12

NU

Units/Quantity

47

HCPCS8

R

5

AN

HCPCS Procedure Code – Addtl

48

HCPCS8Desc

R

255

AN

HCPCS Procedure Code Description

49

Units8

R

12

NU

Units/Quantity

50

HCPCS9

R

5

AN

HCPCS Procedure Code – Addtl

51

HCPCS9Desc

R

255

AN

HCPCS Procedure Code Description

52

Units9

R

12

NU

Units/Quantity

53

HCPCS10

R

5

AN

HCPCS Procedure Code – Addtl

54

HCPCS10Desc

R

255

AN

HCPCS Procedure Code Description

55

Units10

R

12

NU

Units/Quantity

56

HCPCS11

R

5

AN

HCPCS Procedure Code

57

HCPCS11Desc

R

255

AN

HCPCS Procedure Code Description

58

Units11

R

12

NU

Units/Quantity

59

HCPCS12

R

5

AN

HCPCS Procedure Code - Addtl

60

HCPCS12Desc

R

255

AN

HCPCS Procedure Code Description

61

Units12

R

12

NU

Units/Quantity

62

HCPCS13

R

5

AN

HCPCS Procedure Code – Addtl

63

HCPCS13Desc

R

255

AN

HCPCS Procedure Code Description

64

Units13

R

12

NU

Units/Quantity

65

HCPCS14

R

5

AN

HCPCS Procedure Code – Addtl

66

HCPCS14Desc

R

255

AN

HCPCS Procedure Code Description


 

Field #

Field Name

Req.

Len

Type

Notes

67

Units14

R

12

NU

Units/Quantity

68

HCPCS15

R

5

AN

HCPCS Procedure Code – Addtl

69

HCPCS15Desc

R

255

AN

HCPCS Procedure Code Description

70

Units15

R

12

NU

Units/Quantity

71

DX1

R

5

AN

Diagnosis Code

72

DX1Desc

R

255

AN

Diagnosis Code Description

73

DX2

R

5

AN

Diagnosis Code – Addtl

74

DX2Desc

R

255

AN

Diagnosis Code Description

75

DX3

R

5

AN

Diagnosis Code – Addtl

76

DX3Desc

R

255

AN

Diagnosis Code Description

77

DX4

R

5

AN

Diagnosis Code – Addtl

78

DX4Desc

R

255

AN

Diagnosis Code Description

79

DX5

R

5

AN

Diagnosis Code – Addtl

80

DX5Desc

R

255

AN

Diagnosis Code Description

81

DX6

R

5

AN

Diagnosis Code – Addtl

82

DX6Desc

R

255

AN

Diagnosis Code Description

83

DX7

R

5

AN

Diagnosis Code – Addtl

84

DX7Desc

R

255

AN

Diagnosis Code Description

85

DX8

R

5

AN

Diagnosis Code – Addtl

86

DX8Desc

R

255

AN

Diagnosis Code Description

87

CPT/SVC1

R

5

AN

CPT/SVC Code

88

CPT/SVC1Desc

R

255

AN

CPT/SVC Code Description

89

CPT/SVC2

R

5

AN

CPT/SVC Code – Addtl

90

CPT/SVC2Desc

R

255

AN

CPT/SVC Code Description

91

CPT/SVC3

R

5

AN

CPT/SVC Code – Addtl

92

CPT/SVC3Desc

R

255

AN

CPT/SVC Code Description

93

CPT/SVC4

R

5

AN

CPT/SVC Code – Addtl

94

CPT/SVC4Desc

R

255

AN

CPT/SVC Code Description

95

CPT/SVC5

R

5

AN

CPT/SVC Code – Addtl

96

CPT/SVC5Desc

R

255

AN

CPT/SVC Code Description

97

CPT/SVC6

R

5

AN

CPT/SVC Code

98

CPT/SVC6Desc

R

255

AN

CPT/SVC Code Description

99

CPT/SVC7

R

5

AN

CPT/SVC Code – Addtl

100

CPT/SVC7Desc

R

255

AN

CPT/SVC Code Description

101

CPT/SVC8

R

5

AN

CPT/SVC Code – Addtl

102

CPT/SVC8Desc

R

255

AN

CPT/SVC Code Description

103

CPT/SVC9

R

5

AN

CPT/SVC Code – Addtl

104

CPT/SVC9Desc

R

255

AN

CPT/SVC Code Description

105

CPT/SVC10

R

5

AN

CPT/SVC Code – Addtl

106

CPT/SVC10Desc

R

255

AN

CPT/SVC Code Description

107

CPT/SVC11

R

5

AN

CPT/SVC Code

108

CPT/SVC11Desc

R

255

AN

CPT/SVC Code Description

109

CPT/SVC12

R

5

AN

CPT/SVC Code – Addtl

110

CPT/SVC12Desc

R

255

AN

CPT/SVC Code Description

111

CPT/SVC13

R

5

AN

CPT/SVC Code – Addtl

112

CPT/SVC13Desc

R

255

AN

CPT/SVC Code Description

113

CPT/SVC14

R

5

AN

CPT/SVC Code – Addtl

114

CPT/SVC14Desc

R

255

AN

CPT/SVC Code Description


 

Field #

Field Name

Req.

Len

Type

Notes

115

CPT/SVC15

R

5

AN

CPT/SVC Code – Addtl

116

CPT/SVC15Desc

R

255

AN

CPT/SVC Code Description

117

POS

R

2

AN

Place of Service Code

118

POSDesc

R

255

AN

Place of Service Code Description

119

InPat/OutPat

R

1

AN

Inpatient/Outpatient

120

AdmType

O

30

AN

Admission Type

121

ProviderComments

O

1000

AN

Provider of Service Comments

122

AuthComments

O

1000

AN

Authorization Comments

123

AfterTheFactFlag

O

1

AN

After the Fact Indicator – Y/N

124

ActionFlag

R

1

AN

D = Delete

 

Blank = Load/Update

125

UserDefinedText1

O

255

AN

User Defined Text Field 1

126

UserDefinedText2

O

255

AN

User Defined Text Field 2

127

UserDefinedText3

O

255

AN

User Defined Text Field 3

128

UserDefinedDate1

O

8

DT

User Defined Date Field 1

129

UserDefinedDate2

O

8

DT

User Defined Date Field 2

130

UserDefinedDate3

O

8

DT

User Defined Date Field 3

 


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