18.4.66 EHC^E20 - Submit Authorization Request (event E20) (16.3.10)

This message is used to submit a single Authorization Request to a TPA/Payer for authorization (for payment). An Authorization Request is made for one or more patients and may include 1 or more Product/Service Line Items (detail lines), each of which represents a specific, billable item or Payer allowed Treatment Plan.

If the Authorization is approved, then the Payer Application will return either an Authorization Number (Authorization Identifier on AUT) or individual who has authorized the Authorization Request (Name of Authorizer on AUT). The Authorization Number is not the same number as the Authorization Request Number; the latter indicates the number used to identify the request for authorization. The presence of the AUT segment in the EHC^E24 - Authorization Request Response message implies authorization. However, the Authorization may be restricted, which is described as Payer Adjustments.

This message can be used to submit an Authorization Request or to resubmit an Authorization Request (in case it was not properly acknowledged the first time that it was submitted). This message cannot be used to update an Authorization Request (e.g., add or cancel Product/Service Line Items) or cancel an Authorization Request. To cancel an Authorization Request, use the EHC^E21 - Cancel Authorization Request message. To update an Authorization it must first be cancelled (see EHC^E21 - Cancel Authorization Request) and then re-submitted using this message with new Provider control numbers.

Processing Rules:

• The Provider Application and the Payer Application must uniquely identify each Authorization Request, Product/Service Group, Product/Service Line Item and Adjustment. These numbers appear as a pair on the IVC, PSG, PSL and ADJ segments and must be echoed on any subsequent interactions for the Authorization Request, group or line item between the Provider Application and Payer Application.

• The Provider Application and/or Payer Application may also supply a tracking number for each Product/Service Line Item it processes, specified as the Provider Tracking Number or Payer Tracking Number.If the Authorization Request is successfully accepted by the Payer Application, the Provider Application must store up to 2 tracking numbers for each Product/Service Line Item, if present in the message pair. The Payer Application must also store up to 2 tracking numbers for each Product/Service Line Item, if present in the message pair.The Provider Tracking Number and Payer Tracking Number must be echoed on any subsequent interactions for the Product/Service Line Item between the Provider Application and Payer Application.

• This message can contain only one Authorization Request, directed to a single Payer Organization, with multiple patients and multiple insurance policies for each patient. If there are multiple insurance policies and/or Payers identified for authorization, the EHC^E20 - Submit Authorization Request message must be sent to each TPA/Payer.

• Location Identification information, defined by the LOC segment, may be specified with the Authorization Request (header) or Product/Service Line Item.If specified with the Authorization Request (header), then the Location Identification information acts as a default for all Product/Service Line Items in the Authorization Request.If specified with the Product/Service Line Item, then the Location Identification information supersedes (replaces) any defaults set by specifying Location Identification information with the Authorization Request (header).

• Some Payers require Provider information to be included with an Authorization Request, which is defined by the ROL segment. In these situations, the ROL segment may be specified with the Authorization Request (header) and/or Product/Service Line Item.If specified with the Authorization Request (header), then the Provider Information acts as a default for all Product/Service Line Items in the Authorization Request.If specified with the Product/Service Line Item, then the Provider Information supersedes (replaces) any defaults set by specifying Provider information with the Authorization Request (header).Provider Information, if required by the Payer, must be specified with the Product/Service Line Item if it has not been defaulted for the Authorization Request (header).

• Product/Service Clarification Codes: Each Product/Service Line Item allows a number of clarification codes to be specified. These are specified as 2 fields: Product/Service Clarification Code Type and Product/Service Clarification Code Value. Both of these fields repeat within the PSL segment and must repeat the same number of times. For example, if 2 clarification codes are specified, then 2 repetitions of each field is required, the first repetition corresponding to the 1st clarification code, the second repetition corresponding to the 2nd clarification code.