Use when inquiring on authorizations associated with a specific patient.

Use on global inquiries for the status of authorizations associated with multiple patients.

Use this code to request full detail for the available records on the UMO system based on the search criteria provided.

Use this code to request summary information for the available records on the UMO system based on the search criteria provided.

Use this code only if the information source/reviewing entity is an individual, such as an individual primary care physician.

Use until the National PlanID is mandated if the UMO is a payer.

Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has an NPI and it is available to the submitter;
OR
Required for providers before the mandated HIPAA NPI implementation date when the provider has an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.

Signifies the provider making the request.

Cannot be used for Medicare.

Use until the National PlanID is mandated if the requester is a payer.

Use if the requester is a payer.

Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI;
OR
Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI;
OR
Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it.
If not required by this implementation guide, do not send.

Not used if NM108 = 24.

Use to identify the physician, clinic, or group practice.

The social security number must not be used for Medicare. Not used if NM108 = 34.

Use for the requester/provider ID as assigned by the UMO.

Must not contain any characters used as delimiters in this transaction.

Must not contain any characters used as delimiters in this transaction.

Must not contain any characters used as delimiters in this transaction.

Identifies the inquiring provider as the original ordering provider.

Identifes the inquiring provider as the primary care provider of record.

Identifies the inquiring provider as the original referring provider.

The value "II" when used in this data element, shall be defined as "HIPAA Individual Identifier" if this identifier has been adopted. Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of Health and Human Services must adopt a standard individual identifier for use in this transaction.

The code MI is intended to be the subscriber's identification number as assigned by the payer. Payers use different terminology to convey the same number. Use MI - Member Identification Number to convey the following terms: Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.

Use this code only if you cannot determine if the number is a Group Number (6P) or a Policy Number (IG).

Use this code only if the subscriber is the patient.
The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

Use the NM1 (Subscriber Name) segment if the subscriber's HIC number is the primary identifier for his or her coverage. Use this code only in a REF segment when the payer has a different member number, and there is also a need to pass the subscriber's HIC number. This might occur in a Medicare HMO situation.

Use this code when the Identity Card Number differs from the Member Identification Number. This is particularly prevalent in the Medicaid environment.

Use this code only if the Social Security Number was not used by the payer as its primary method of identifying the subscriber. Do not use the social security number if the information source is Medicare.

The maximum number of characters to be supported for this qualifier is `20'. Characters beyond the maximum are not required to be stored nor returned by any receiving system.

The social security number may not be used for Medicare.

Use to limit the inquiry to information on requests for admission to a facility.

Use to limit the inquiry to information on requests for service reviews related to an episode of care.

Use to inquire on the status or existence of service reservations.

Use to limit the inquiry to information on requests for referrals.

Use this value only for appeals of review decisions where the level of service required is emergency or urgent.

Use this value for appeals of review decisions where the level of service required is not emergency or urgent.

Indicates that this is an extension request to a prior approved service.

This code is used to request the UMO to reconsider a previously denied referral or certification.

Various services, such as physical therapy, spinal manipulation, and allergy treatment, have both a delivery pattern and a time span of authorization. Many UMOs place time limits - as in will not authorize anything for more than 30 days at a time. For example, blanket authorization for allergy treatments as required for 30 days. At the end of the 30 days, the provider must request to renew the certification - not extend it - because the UMO authorizes for 30 day intervals, one interval at a time.

Use if the requester is revising the specifics of a certification for which services have not been rendered. For example, the requester may be requesting additional procedures or other procedures for the same patient event.

Use for restorative dental.

Use this code to inquire on authorizations with a status of complete. For the UMO, the authorization is complete at the time the claim is received and recorded.

Use this code to inquire on authorizations with a status of expired. For the UMO, this is based on the effective period for which the original certification was authorized.

Use this code to inquire on authorizations with a status of partially certified. Consult HCR01, Loop 2000F for approved, denied or pended services.

Use this code to inquire on authorizations with a status of denied. Note, however, that the UMO might not retain information on health care services reviews that it has denied.

Use this code to inquire on authorizations with a status of certified with modifications.

Use this code to inquire on authorizations with a cancelled status. For the UMO, this is an administrative cancellation due to a change in the status of the patient and/or service provider.