X12 EDI Examples with Prior Authorization Number

EDI 837 Professional. Version 005010X222A1

Example 6:   Prior Authorization

There are certain services that require pre-certification, pre-notification or pre-authorization from the insurance company. On the insurance verification process, we can ensure whether a particular service requires pre-authorization or not. Though pre-authorization does not guarantee reimbursement, the absence of pre-authorization can surely result in  claim denials or non-reimbursement. Once you acquire pre-authorization from a payer, you will get a pre-authorization number. This number must be included in your claims to avoid unnecessary denials. If your claims are denied based on the lack of medical necessity, you should append this pre-authorization number while preparing an appeal letter.   

 

ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *210510*0744*^*00501*107435800*1*T*:
GS*HC*123123*241232*20210510*0744*1074358*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210510*0744*CH
NM1*41*2*ABC Submitter*****46*7342343
PER*IC*John Mike*TE*1214151617
NM1*40*2*Zirmed*****46*12345
HL*1**20*1
PRV*BI*PXC*208500000X
NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692
N3*3937  Kenwood Place
N4*Orlando*FL*32801
REF*EI*81-3777631
HL*2*1*22*0
SBR*P*18*92291223*AED12342*****ZZ
NM1*IL*1*BAKER*Alyssa****MI*723223232
N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St
N4*HOUSTON*TX*77833
DMG*D8*20201203*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*100.00***11:B:1*Y*A*Y*Y*P
REF*G1*X4124124
HI*ABK:R1013*ABF:E860
NM1*82*1*Nelson*Romer****XX*1023555349
NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059
N3*6100 W CREEK RD SUITE 35
N4*Independence*OH*44131
LX*1
SV1*HC:99213*50.00*UN*1.00***1:2
DTP*472*D8*20201203
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00***1:2
DTP*472*D8*20201203
REF*6R*6002
SE*36*0001
GE*1*1074358
IEA*1*107435800


HTML Version  

Interchange Control Header

Authorization Qualifier 00
Security Qualifier 00
Interchange ID Qualifier Sender ZZ
Submitter ID 123123
Interchange ID Qualifier Receiver ZZ
Receiver ID 241232
Interchange Date 05/10/2021
InterChange Time (HHMM) 07:44
Repetition Seperator ^
Control Number 107435800
Acknowledgement Requested 1
Usage Indicator T

Functional Group Header

Application Sender Code 123123
Application Receiver Code 241232
Group Transaction Date 05/10/2021
Group Transaction Time (HHMM) 07:44
Group Control Number 1074358
EDI Version 005010X222A1

Transaction Set Header

Transaction set 837
Transaction Control Number 0001

Hierarchical Transaction

Application Transaction Number 0001
Transaction Date 05/10/2021
Transaction Time (HHMM) 07:44

Submitter Information

Submitter Entity Organization
Organization Name ABC Submitter
Etin Number 7342343
Contact Name John Mike
Contact Phone 1214151617

Receiver Information

Receiver Name Zirmed
Receiver Etin Number 12345

Billing Provider

Entity Type 2
Last or Organization Name Get Well Family Clinic LLC
Address1 3937 Kenwood Place
City Orlando
State FL
Zip 32801
NPI 1740713692
Tax ID 81-3777631
Taxonomy Code 208500000X

Subscriber information

Payer Responsbility P
Insured Relationship 18
Group Number 92291223
Group Name AED12342
Claim Filling Indicator ZZ

Subscriber Name

Entity Type 1
Last or Organization Name BAKER
First Name Alyssa
DOB 12/03/2020
Gender M
Policy No 723223232
Address1 197800 Atascocita Shores Dr
Address2 302 12 N. Mcgraw St
City HOUSTON
State TX
Zip 77833

Payer

Name CIGNA
Address1 PO BOX 660044
City DALLAS
State TX
Zip 75266
Payer ID 81400

Claim Information

Claim No 10421
Billed Amount 100.00
Claim Type 1
Provider Sign Indicator Y
Provider Accept Assignment Code A
Benefits Assignment Indicator Y
Release of information Y
Prior Authorization Number X4124124

ICD Information

ICD Code 1 R1013
ICD Code 2 E860

Rendering Provider

Entity Type 1
Last or Organization Name Nelson
First Name Romer
NPI 1023555349

Facility

Name Clinic For Pain And Anxiety
Address1 6100 W CREEK RD SUITE 35
City Independence
State OH
Zip 44131
NPI 1396885059

Line Item : 1

Line Item ID 6001
Procedure Code 99213
Units Code UN
Units 1.00
Charges 50.00
ICD Pointers 1,2
Service From Date 12/03/2020
Service To Date 12/03/2020

Line Item : 2

Line Item ID 6002
Procedure Code 87070
Units Code UN
Units 1.00
Charges 50.00
ICD Pointers 1,2
Service From Date 12/03/2020
Service To Date 12/03/2020



CMS 1500 Form Preview for the above EDI File

cms1500-2021-05-10-7-01-am-1

Looking for JSON to EDI solution ?

EDI RESTful Web Service API
JSON To EDI 837 Professional

Looking for more examples ? Login into our EDI Tool
https://demo.nagatabilling.com/NagataEDITool/login.zhtml