Transaction Details

A request for authorization for outpatient community mental health services.

Transaction ID	Transaction Description	Status	Status Date
960.00	Authorization Request	Final	4/1/2010

Key	Field ID	Field Code	Field Name	Field Description	Actions Allowed	Char Length
	101073	CV01	RCODE	Transaction ID	NN	6
	030010	CV02	RACTION	Action Code	NN	1
	030760	CV03	RSNID	RSN Report Unit	NN	3
K	030020	CV04	RORG	Agency Reporting Unit ID	NN	5
K	030001	CV05	RLGUID	Unique Identifier	NN	11
	030620	CV06	PN	Master Client Number	NN	11
	200627	RV01	intkstf	Assessment Clinician Name (LName, FName)	NA	70
	200622	RV02	sitest	Main Site Address Line 2	NA	40
	200625	RV03	sitecity	Main Site City	NA	20
	200626	RV04	sitezip	Main Site ZIP Code	NA	10
	200623	RV05	sitetel	Main Site Telephone Number	NA	20
	200624	RV06	sitefax	Intake Staff Site Fax Number	NA	20
	200643	RV07	autdt	Date of Authorization Request	NA	8
	200644	RV08	auttm	Time of Authorization Request	NA	4
	200657	RV09	staffnpi	Staff National Provider Identification	NA	80
	200272	RV10	faccd	Assessment Facility Code	NA	5
	200645	RV11	orgein	Organization Employer Identification Number	NA	10
	030710	RV12	princdia	Principal Diagnosis	NA	6
	200646	RV13	diagdt	Diagnosis Date	NA	8
	200647	RV14	adlguid	GUID of Additional Authorization Request Info.	NA	11
	200648	RV15	idqual	Subscriber Supplemental ID-Reference ID Qualifier	NA	2
	200649	RV16	id	Subscriber Supplemental ID-Reference ID	NA	11
	200650	RV17	orgnpi	Organization National Provider Identification	NA	80
	200651	RV18	certtyp	Certification Type Code (Authorization)	NA	1
	200652	RV19	svctyp	Service Type Code	NA	2
	030750	RV20	roicd	Release of Information Code	NA	1
	200654	RV21	prioraut	Previous Authorization Number	LA
	200655	RV22	sautper	Proposed Start of Authorization Period	NA	8
	200656	RV23	eautper	Proposed End of Authorization Period	NA	8
	200670	RV24	staffid	Reviewd By
	200671	RV25	reviewtime	Timestamp of the Authorization Review
	200672	RV26	actcd	Review Action Code
	200673	RV27	rejectcd	Reject Reason
	200674	RV28	asauth	Assigned Authorization Number
	200675	RV29	apprstdt	Approved Start Date
	200676	RV30	apprenddt	Approved End Date

Field ID	Validation	CodeTable
030001	001 - Value Cannot Be Null
030010	001 - Value Cannot Be Null
030010	002 - Code Invalid	ACODE
030020	001 - Value Cannot Be Null
030020	002 - Code Invalid	ORG
030620	001 - Value Cannot Be Null
030710	001 - Value Cannot Be Null
030710	002 - Code Invalid	DIAG
030750	001 - Value Cannot Be Null
030750	002 - Code Invalid	ROI
030760	001 - Value Cannot Be Null
101073	001 - Value Cannot Be Null
200272	001 - Value Cannot Be Null
200272	002 - Code Invalid	FACCD
200622	001 - Value Cannot Be Null
200623	001 - Value Cannot Be Null
200624	001 - Value Cannot Be Null
200625	001 - Value Cannot Be Null
200626	001 - Value Cannot Be Null
200627	001 - Value Cannot Be Null
200643	001 - Value Cannot Be Null
200643	020 - Date may not be in the future.
200644	001 - Value Cannot Be Null
200645	001 - Value Cannot Be Null
200646	001 - Value Cannot Be Null
200646	020 - Date may not be in the future.
200647	001 - Value Cannot Be Null
200648	001 - Value Cannot Be Null
200649	001 - Value Cannot Be Null
200650	001 - Value Cannot Be Null
200651	001 - Value Cannot Be Null
200651	002 - Code Invalid	CERTY
200652	001 - Value Cannot Be Null
200652	002 - Code Invalid	SVCTY
200655	001 - Value Cannot Be Null
200656	001 - Value Cannot Be Null
200657	001 - Value Cannot Be Null
200672	002 - Code Invalid	HCRAC
200673	002 - Code Invalid	REJEC

Note_Date	Note
	Items from this table come from the HIPAA 278 transaction
	Certification Type Code - Most likely codes used and when: R - Renewal-Reauth of current auth; I - Initial-Where there is not a current authorization being renewed; S - Revised-When there is a change in level; 4 - Extension-May need for complaint / grievance / appeal.
12/11/2006	Field IDs 200670 through 200676 are not included in the incoming authorization request transaction. These fields are part of the authorization process and data is input into these fields when they Quality Specialists do their review of the authorization request. These fields are listed here for table documentation purposes only.
7/10/2007	20070701 - RSN -> MHD Send definition uses the fields defined for the 063.01 transaction.
7/8/2009	Starting with the implementation of ProviderOne, use the client's ProviderOne Client ID in field 'id' (200649) when the value for 'idqual' (200648) = 'NQ' and, at the time of the request, the client has a valid Medicaid mental health benefit. If the client does not have a valid Medicaid mental health benefit at the time of the request, use the client's PN in field 'id' and use the value of 'EJ' in field 'idqual'. PIC codes will no longer be accepted in this field. Once ProviderOne is implemented, NSMHA will reject all auth requests submitted with a legacy PIC.
7/8/2009	Changed the Character Length of 'id' (200649) from 14 to 11.

North Sound
Mental Health Administration

NSMHA-CIS Data Dictionary

Authorization Request

Transaction

Transaction Details

Validations

Transaction Notes

North Sound Mental Health Administration

NSMHA-CIS Data Dictionary

Authorization Request

Transaction

Transaction Details

Validations

Transaction Notes

North Sound
Mental Health Administration