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Data Elements Related to Prior Authorization Transfer

Name: Prior Authorization Transfer
Definition: Transferring existing prior authorization data between payer/processors when transitioning clients, performing system database or platform changes.
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Additional Message InformationFree text message.
Alternate ID NumberAlternate ID number assigned to the cardholder or family member.
Batch NumberA number generated by the sender to uniquely identify this batch from others, especially when multiple batches may be sent in one day.
Benefit AmountRepresents the amount of the overridden amount to be applied in place of the standard plan benefit.
Benefit Amount Time PeriodDefines how the Benefit Amount Type override is to be applied during a time period and corresponds to the plan's benefit accrual period.
Benefit Amount TypeRepresents which of the benefit accumulation types is being overridden and also has an option to override all benefit amounts. This amount is usually set to an amount outside of the normal plan benefit coverage level.
Benefit Amount Used To-DateIndicates the aggregated amount of benefit used to date against a previously approved override amount.
Cardholder IDInsurance ID assigned to the cardholder or identification number used by the plan.
Claim Cost Ceiling Override AmountRepresents either the specific copay Gross Amount Due or the Gross Amount Due Ceiling that the prior authorization is overriding.
Claim OriginationFrom the plan's perspective, the method/system/application by which the payer received the claim.
Client NameName of client.
Compound IndicatorCode indicating if the prior authorization applies to compounded products only.
Copay/Coinsurance Override AmountRepresents either the specific copay dollar amount or coinsurance rate that is defined in the prior authorization and is qualified by the Copay/Coinsurance Override Type (A08).
Copay/Coinsurance Override TypeIndicator used to represent whether or not the override is defined as a flat dollar amount or as a percentage, and is usually outside of the normal plan benefit coverage level. Percentage may be considered a coinsurance amount.
Copay Conjunction SequenceThe sequence in which a multi-tiered copay structure should be applied.
Creation DateDate the file was created.
Creation TimeTime the file was created.
Date Of BirthDate of birth of patient.
Days SupplyEstimated number of days the prescription will last.
Days Supply Used to DateAccumulated authorized amount of days supply used to date
Dispense As Written (DAW) DifferenceIndicator to determine where the cost differential of the DAW difference should be shifted.
Dosage Per DayThe dosage per day that is approved by the prior authorization and is usually over or under the normal plan limits or clinical guidelines.
Drug TypeCode to indicate the type of drug dispensed.
File TypeCode identifying whether the file contained is test or production data.
Fills/Refills Used To-DateIndicates the number of fills or refills used to date by a patient against an existing Annual Fill or Annual Refill override.
First NameFirst name.
Group IDID assigned to the cardholder group or employer group.
Last NameLast name.
Middle InitialIndividual middle initial.
Patient First NameIndividual first name.
Patient Gender CodeCode indicating the gender of the individual.
Patient IDID assigned to the patient.
Patient ID QualifierCode qualifying the 'Patient ID' (332-CY).
Patient Last NameIndividual last name.
Patient Relationship CodeCode indicating relationship of patient to cardholder.
Person CodeCode assigned to a specific person within a family.
Prescriber IDID assigned to the prescriber.
Prescriber ID QualifierCode qualifying the 'Prescriber ID' (411-DB).
Prescriber Override TypeThe override's inclusion or exclusion parameters as it applies to the prescriber network for a plan.
Prescription/ Service Reference NumberReference number assigned by the provider for the dispensed drug/product and/or service provided.
Prescription/Service Reference Number QualifierIndicates the type of billing submitted.
Previous Date of FillDate prescription was previously filled.
Prior Authorization Create DateThe date the prior authorization record was created in sender's system.
Prior Authorization Effective DateDate the prior authorization became effective.
Prior Authorization Expiration DateDate the prior authorization ends.
Prior Authorization Number-AssignedUnique number identifying the prior authorization assigned by the processor.
Prior Authorization Number of Fills AuthorizedThe number of fills allowed to be covered by the prior authorization and is usually over or under the normal plan limitations.
Prior Authorization Number Of Refills AuthorizedNumber of refills authorized by the prior authorization.
Prior Authorization Number SubmittedNumber submitted by the provider to identify the prior authorization.
Prior Authorization QuantityAmount authorized expressed in metric decimal units.
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